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11060226 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 1196 ELMSFORD DR CONTRACTOR:CHETAUD PRO BUILDERS PERMIT NO: 11060226 OWNER'S NAME: ED CHEN 63 KENNEDY AVE DATE ISSUED:06/29/2011 OWNER'S PHONE: 4083134030 CAMPBELL,CA 95008 PHONE NO:(408)313-4030 L LICENSED CONTRACTOR'S DECLARATIONr �Oz�� BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class Lic.# MECH RESIDENTIAL� COMMERCIAL Contractor Date 6 l/ I hereby affi t m licensed under the provisions of Ch Ater 9 JOB DESCRIPTION:TEMP POWER POLE HOOK-UP (commenc' with Section 7000)of Division 3 of the Business&Professions Code an at 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:$300 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 permit is issued. APN Number:36209002.00 Occupancy Type: APPLICANT CERTIFICATION 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 PERMIT EXPIRES IF WORK IS NOT STARTED to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We)agree to save WITHIN 180 DAYS OF PERMIT ISSUANCE OR indemnify and keep harmless the City of Cupertino against liabilities,judgments, 180 DAYS OM AST CALLED INSPECTION. costs,and expenses which may accrue against said City in consequence of the granting of this permit. dif e a icant understands and will comply r with all non-point so c ulati er Cupertino Municipal Code,Section Issued by: 9.18. Signature Date 7 l/ RE-ROOFS: OWNER-BUILDER DECLARATION All roofs shall be inspected prior to any roofing material being installed.If a roof is installed without first obtaining an inspection,I agree to remove all new materials for I hereby affirm that I am exempt from the Contractor's License Law for one of inspection. the following two reasons: 1,as owner of the property,or my employees with wages as their sole compensation, Signature of Applicant: Date: 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 ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER construct the project(Sec.7044,Business&Professions Code). I hereby affirm under penalty of perjury one of the following three HAZARDOUS MATERIALS DISCLOSURE declarations: I have read the hazardous materials requirements under Chapter 6.95 of the I have and will maintain a Certificate of Consent to self-insure for Worker's California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain Compensation,as provided for by Section 3700 of the Labor Code,for the compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health& performance of the work for which this permit is issued. Safety Code,Section 25532(a)should I store or handle hazardous material. I have and will maintain Worker's Compensation Insurance,as provided for by Additionally,should I use equipment or devices which emit hazardous air Section 3700 of the Labor Code,for the performance of the work for which this contaminants as defined by the Bay Area Air Quality Management District I will permit is issued. maintain compliance withJhn Cupe ino Municipal Code,Chapter 9.12 and the &Safe - 5,25533,and 25534. o ,Sec ns 2 0 [certify that in the performance of the work for which this permit is issued,l shall Health not employ any person in any manner so as to become subject to the Worker's Owner th i Compensation laws of California. If,after making this certificate of exemption,I Date: become subject to the Worker's Compensation provisions of the Labor Code,I must forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY I ereby affirm that there is a construction lending agency for the performance of work's APPLICANT CERTIFICATION for which this permit is issued(Sec.3097,Civ C.) I certify that I have read this application and state that the above information is Lender's Name 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 Lender's Address upon the above mentioned property for inspection purposes.(We)agree to save indemnify and keep harmless the City of Cupertino against liabilities,judgments, ARCHITECT'S DECLARATION c- and expenses which may accrue against said City in consequence of the �g of this permit.Additionally,the applicant understands and will comply I understand my plans shall be used as public records. w....all non-point source regulations per the Cupertino Municipal Code,Section 9.18. Licensed Professional Signature Date CITY OF CUPERTINO 6 ITEMS OF 6 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN . . . . . . . . : 36209002. 00 DATE ISSUED. . . . . . . : 06/29/2011 RECEIPT #. . . . . . . . . : BS000013927 REFERENCE ID # . . . : 11060226 SITE ADDRESS . . . . . : 1196 ELMSFORD DR SUBDIVISION . . . . . . CITY . . . . . . . . . . . . . . CUPERTINO IMPACT AREA . . . . . . OWNER . . . . . . . . . . . . . ED CHEN ADDRESS . . . . . . . . . . : 1196 ELMSFORD DR CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM . . . . : LOUIS RYAN CHETAUD CONTRACTOR . . . . . . . : LIC # 32681 COMPANY . . . . . . . . . . : CHETAUD PRO BUILDERS ADDRESS . . . . . . . . . . : 63 KENNEDY AVE CITY/STATE/ZIP . . . : CAMPBELL, CA 95008 TELEPHONE . . . . . . . . : (408) 313-4030 FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- ---------- -ADMIN HOURS 0 .50 39. 00 0. 00 39.00 0. 00 1BCBSC VALUATION 300 . 00 1. 00 0. 00 1 .00 0. 00 1BSEISMICR VALUATION 300 . 00 0. 50 0. 00 0 .50 0. 00 1EPERMITFE FLAT RATE 1. 00 42. 00 0. 00 42 .00 0. 00 1ERT<200 UNITS 1. 00 42. 00 0. 00 42 .00 0. 00 1TRAVDOC FLAT RATE 1 . 00 42 . 00 0. 00 42 . 00 0.00 ---------- ---------- ---------- ---------- TOTAL PERMIT 166.50 0 . 00 166.50 0. 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CREDIT CARD 166.50 VISA --------------- TOTAL RECEIPT 166.50 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 402 TEMPORARY POWER Building Department 1[a City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014-3255 Telephone: 408-777-3228 C U P E RT I N O Fax: 408-777-3333 CONTRACTOR/ SUBCONTRACTOR LIST JOB ADDRESS: /196 b i PERMIT# OWNER'S NAME: . C E PHONE# GENERAL CONTRACTOR: ( o,,& -_ 3. BUSINESS LICENSE# ADDRESS: ( �(�, (�.�.h CITY/ZIPCODE: *Our municipal code requires all businesses working in the city to have a City of Cupertino business license. NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE GENERAL CONTRACTOR AND ALL SUBCT HAVE OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE. / I am not using any subcontractors: Z �� Signature 16ate Please check applicable subcont ctors and complete the following information: SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets & Millwork Cement Finishing Electrical Excavation Fencing Flooring / Carpeting Linoleum/Wood Glass / Glazing Heating Insulation Landscaping Lathing Masonry Painting/Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile ; �" O ner/-Contractor Signature Date CITY OF CUPERTINO FEE ESTIMATOR-BUILDING DIVISION ADDRESS: 1196 elmsford dr. DATE: 06/29/2011 REVIEWED BY: bobs. APN: BP#: "VALUATION: $300 y°PERMIT TYPE: Electrical Permit PLAN CHECK TYPE: Alteration /Addition/ Repair PRIMARY SFD or Duplex PENTAMATION 1 REAP14 USE: PERMIT TYPE: WORK temp power pole SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Temporary Power 1ERT<200 100 Amps $42 TOTALS: $42.00 Elec.Plan Check 0.0 1 F-77hrs $0.00 Elec.Permit Fee: IEPERMIT Other Elec.Insp. 0.0 hrs $42.00 NOTE. Thesefees are based on the preliminary information available and are only an estimate. Contact the De t or addn'1 info, FEE ITEMS (P'ee/zesolution 09-051 I f'. ',;I%10) FEE QTY/FEE MISC ITEMS PME Plan Check: $0.00 PME Unit Fee: $42.00 PME Permit Fee: $42.00 Work Without Permit? 0 Yes G No $0.00 Travel Documentation Fee: ITRA VDOC $42.00 Strong Motion Fee: IBSEISMICR $0.50 0.5 hrs Admin./Clerical Fee Bldg;Stds Commission Fee: IBCBSC $1.00 $39.00 ]ADMIN F- SUBTOTALS: $127.50 $39.00 TOTAL FEE:' $166.50 Revised: 04/29/2011 GENERAL PERMIT APPLICATION MEP COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 10300 TORRE AVENUE •CUPERTINO, CA 95014-3255 CUPERTINO (408)777-3228• FAX(408)777-3333• buildingQcupertino.org MIC S ❑PLUMBING ❑MECHANICAL CTRICAL MISCELLANEOUS PROJECT ADDRESS / APN#L:54 2, 001 (Dv 2— OWNERNAMEr — c/ 'F PHONE,r j � � � � f 0E MAII. D CVL � �1�J `�U l �C7Ll�`'✓� cp/ ''V2"�� r� STREET ADDRESS CITY, STATE,ZIP // FAX /6)g J ! CONTACT NAME PHONE E-MAIL / STREET ADDRESS /'� � � � CITY,STATE, ZIP/?� i/ / /� FAX fj ,, ❑ OWNER ❑ OWNER-BUIIAER ❑ OWNER AGENT IJJ�ONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME LICENSE NUMBE)3,z 3 LICENSE TYPE BUS.LIC# r (� COMPANY NAME//^l ` S i _ i ` �f E MAILLT FAX r 'I STREET ADDRESS- 2 } V_ CITY,STATE,ZIP�� / PHONE ARCHITECT/ENGINEER NAME �4 LICENSE NUMBER ( BUS.LIC# COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE USE OF SFD or DUPLEX ❑ MULTI-FAMILY PROJECT IN WILDLAND ❑ YES PROJECT IN ❑YES IS THE BLDG AN ❑ YES BUILDING: ❑COMMERCIAL URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑NO EICHLER HOME? ❑NO DESCRIPTION OF WORK i 7 TOTALVALUATION: RECEIVED BY: By my signature below,I certify to each of the foe, in pro owner or authorized agent to act on the property owner's behalf I have read this application and the information I have provide co ct. re e Description of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating to buildin ons c' autho representatives of Cupertino to enter the above-id 'fled prop for inspection pu{poses. Signature of Applicant/Agent: > Date: Vden /� S�r AL INFORMATION REQUIRED OFFICE USE ONLY ❑ OVER-THE-COUNTER c ❑ EXPRESS X U ri ❑ STANDARD U ❑ LARGE a ❑ MAJOR MEPMiscApp_2011.doc revised 06121/11