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13110033 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 21351 VAI AVE CONTRACTOR:ALPS CONSTRUCTION& PERMIT NO: 13110033 REMODELING OWNER'S NAME: PANG JASON L AND WUWANICH WOLALAK 1011 S DE ANZA BLVD DATE ISSUED: 11/06/2013 OWNER'S PHONE: 4083099555 SAN JOSE,CA 95129 PHONE NO:(408)898-6474 ❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL COMMERCIAL EI License Class_ Lie.# 1- 7� INSTALL TEMP POWER Contractor DateA.16 W13 I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000)of Division 3 of the Business&Professions Code and that my license is in full force and effect. I hereby affirm under penalty of perjury one of the following two declarations: I have and will maintain a certificate of consent to self-insure for Worker's Compensation,as provided for by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. Sq.Ft Floor Area: Valuation:$200 I have and will maintain Worker's Compensation Insurance,as provided for by Section 3700 of the Labor Code,for the performance of the work for which this APN Number:36205044.00 Occupancy Type: permit is issued. APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED correct.I agree to comply with all city and county ordinances and state laws relating WITH 0 DAYS OF PERMIT ISSUANCE OR to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We)agree to save 180 D OM LAST CALLED INSPECTION. indemnify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City in consequence of the granting of this permit. Additionally,the applicant understands and will comply Issued by: Date: with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. 1 / RE-ROOFS: Signature Date r /'z All roofs shall be inspected prior to any roofing material being installed.If a roof is J installed without first obtaining an inspection,I agree to remove all new materials for inspection. ❑ O -BUILDER DECLARATION Signature of Applicant: Date: I hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER I,as owner of the property,or my employees with wages as their sole compensation, will do the work,and the structure is not intended or offered for sale(Sec.7044, Business&Professions Code) I,as owner of the property,am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE construct the project(Sec.7044,Business&Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the California Health&Safety Code,Sections 25505,25533,and 25534. I will I hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the declarations: Health&Safety Code,Section 25532(a)should I store or handle hazardous I have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally,should I use equipment or devices which emit hazardous Compensation,as provided for by Section 3700 of the Labor Code,for the air contaminants as defined by the Bay Area Air Quality Management District I performance of the work for which this permit is issued. will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sections 5,25533,and 25534. Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agent: te: 'J 1 permit is issued. I certify that in the performance of the work for which this permit is issued,I shall i not employ any person in any manner so as to become subject to the Worker's Compensation laws of California. If,after making this certificate of exemption,I CONSTRUCTI N LADING AGENCY become subject to the Worker's Compensation provisions of the Labor Code,I must I hereby affirm that there is a construction lending agency for the performance of forthwith comply with such provisions or this permit shall be deemed revoked. work's for which this permit is issued(Sec.3097,Civ C.) Lender's Name APPLICANT CERTIFICATION Lender's Address I certify that I have read this application and state that the above information is correct.I agree to comply with all city and county ordinances and state laws relating to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes.(We)agree to save ARCHITECT'S DECLARATION indemnify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records. granting of this permit.Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code,Section Licensed Professional 9.18. Signature Date GENERAL PERMIT APPLICATION MEP 19 COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 IO CUPERTINO (408)777-3228• FAX(408)777-3333•buildingancupertino.org ' MISC [:1 PLUMBING El MECHANICAL/ ❑ELECTRICAL [:]MISCELLANEOUS PROJECT ADDRESS 2d f V� APN# V(A ' A OWNERNAME 0,5 ,,j Djy �^v PHO /�j 0� 17 E-MAIL STREET ADDRESS l I �� MCITY, STATE,ZIP /' k �r'`� q N^ ra FAX CONTACT NAE L� PHO O Q, R ,_ ill E-MAIL'i•s ✓,� �� 2 STREET ADDRESS !, Aq CITY,STAA,ZIP 6 (6} n 1 ) 1 -rjC� glwo 11 OWNER 11OWNER-BUILDER ❑ OWNER AGENT CONTRACTOR 11 CONTRACTOR ,CONTRACTOR AGENT `' ARCHITECT 11 ENGINEER 11 DEVELOPER 11 TENANT "I Llv CONTRACTOR NAME p i LICENSE NUMBER nA � LICENSE TYPE '�G BUS.LIC# COMPANY NAME �JL„ .Lo E-MAIL _`�' FAX �t ✓�V�crlIQVI C _ (or1S fr C�10�� �o "[ r 1T STREET ADDRESS ' CITY,STATE,ZIP _ ,� P O� ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC# COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE USE OF ❑SFD or DUPLEX ❑ MULTI-FAMILYPROJECT IN WI.DLAND ❑ YES PROJECT IN ❑YES IS THE BLDG AN ❑YES BUILDING: ❑COMMERCIAL URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑NO �EICHLFRHOME? ❑ NO DESCRIPTION OF WORK yi- v_ic�e TjeeQqPax-n_a1q i f r, I I,� a ri 16r_j�a 4 TOTAL VALUATION: RECEIVED BY: By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on thip5oerty owner's behalf. I have read this application and the information I have pr id d is correct. I have read the Description of Work and verify it is accur . I agree to comply with all applicable local ordinances and state laws relating di onstruction. I authorize representatives of Cupertino to enter the above-iden Pied prop for inspection purposes. Signature of Applicant/Agent: Date: SUPPLEMEN AL INFORMATION REQUIRED oaiE sE ONLY, Ni VERrTkF•OIJNTER' Jz Tt ft, 01 g ❑ STANDARD '�� 5 3 ^i" � Q LA�;GE. +� U, MAJQR, v� MEPMiscApp_2011.doc revised 06/21/11 CITY OF CUPERTINO FEE ESTIMATOR— BUILDING DIVISION ADDRESS: 21351 DATE: 11/06/2013 REVIEWED BY: mendez APN: BP#: `VALUATION: $200 *PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration/ Repair PRIMARY SFD or Duplex PENTAMATION 1REAP14 USE: PERMIT TYPE: WORK install temp power SCOPE t-"Col 1""'a",Ubo A Pb(lo,71,. 11,„,Ch, Elec.Plan Check 0.0 1 hrs $0.00 ti<<'e711 low Elec.Permit Fee: IEPERMIT E1__L_ Orh� P`trrrar',7r<<,�� Other Elec.Insp. 0.0 hrsL7.00 FT_L_ _bled, Ins1�. lr,e 1'.rtrurl,. t,,s/�, T'ee1�I<'c. Ir>ip tr�i�: NOTE:This estimate does not include fees due to other Departments(i.e.Planning,Public Works,Fire,Sanitary Sewer District,School District,etc). Thesefees are based on the preffinWdna information available and are only an estimate. Contact the De t or addn 7 info. FEE ITEMS(Fee Resolution I1-053 E f 7/1,113) FEE QTY/FEE MISC ITEMS Plan Check Fee: $0.00 F-2-007 amps Electrical Suppl. PC Fee: Q Reg. © OT FO.0 Fhrs $0.00 $47.00 IERT<200 Temporary Power PME Plan Check: $0.00 Permit Fee: $0.00 Suppl. Insp. Fee-0 Reg. Q OT 0.0 1 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $47.00 (."onstrrretion TLV., Administrative Fee: IADMIN $44.00 Work Without Permit? 0 Yes (E) No $0.00 Advanced Planning Fee: $0.00 Select a Non-Residential Travel Documentation Fee: ITRA VDOC $47.00 Building or Structure i Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $1.00 SUBTOTALS: $139.50 $47.00 TOTAL FEE: $186.50 Revised: 10/01/2013