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13100179 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10721 JOHNSON AVE CONTRACTOR:DWK CONSTRUCTION PERMIT NO:13100179 OWNER'S NAME: WANG FENG WEN AND CHANG HUI-FEN 18665 LOREE AVE DATE ISSUED:10/28/2013 OWNER'S PHONE: 4085673014 CUPERTINO,CA 95014 1 PHONE NO:(408)996-1186 ❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL El COMMERCIAL Lic.# (A'?��y�7 TEMPORARY POWER POLE License Class Contractor (-/� ,21 S e77&X, /ZL Date 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 Valuation:$8000 performance of the work for which this permit is issued. Sq.Ft Floor Area: 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:37531054.00 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 WITHIN 180 DAYS PF PERMIT ISSUANCE OR to building construction,and hereby authorize representatives of this city to enter CALLED INSPECTION. upon the above mentioned property for inspection purposes. (We)agree to save 180 DAYS 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 b Date: VA� granting of this permit. Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. RE-ROOFS: _ .. D ? All roofs shall be inspected prior to any roofing material being installed.If a roof is Signature i Date p installed without first obtaining an inspection,I agree to remove all new materials for inspection. ❑ OWNER-BUILDER DECLARATION Signature of Applicant: Date: I hereby affirm that I am exempt from the Contractor's License Law for one of ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER the following two reasons: 1,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) HAZARDOUS MATERIALS DISCLOSURE 1,as owner of the property,am exclusively contracting with licensed contractors to 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 Health&Safety Code,Section 25532(a)should I store or handle hazardous declarations: nt to self-insure for Worker's material. Additionally,should I use equipment or devices which emit hazardous 1 have and will maintain a Certificate of Consey the Bay Area Air Compensation,as provided for by Section 3700 of the Labor Code,for the wilcontaminants main ainacompliance' wined th the Cupertino MunicipalniCode,Chapter 9.12 and performance of the work for which this permit is issued. the Health&Safety Code,Sections 255059 25533,and 25534.. I have and will maintain Worker's Compensation Insurance,as provided for by 7 �O > Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agent: Dat . permit is issued. I certify that in the performance of the work for which this permit is issued,I shall not employ any person in any manner so as to become subject to the Worker's CONSTRUCTION LENDING AGENCY Compensation laws of California. If,after making this certificate of exemption,I become subject to the Worker's Compensation provisions of the Labor Code,I must whereby for which thithat s permit is re is a issurm ed(Sec.lendingnstruction 3097,C v C.)for the performance of forthwith comply with such provisions or this permit shall be deemed revoked. 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 sate 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 COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 �� CUPERTINO (408)777-3228• FAX(408)777-3333•building aecupertino.org MISC [:1 PLUMBING MECHANICAL RIELECTRICAL ❑MISCELLANEOUS PROJECT ADDRESS %C Z/ S /_/75� _!, APN# -3F —3 / — ' [Z 7 v jdJVC- � T OWNER NAME PHONE E-MAIL i-✓e� Gv � �f�� STREET ADDRESS CITY, STATE,ZIP FAX a - 6yl Lc .-h. eA s l4 CONTACT NAME PHONE E-MAIL `jONt61- C'Gtcr�n & 3� 3 S- �lu%kcoyrsCot-v STREET ADDRESSI // f•- � �• CITY,STATE,ZIPS, �Ir�' G l,/ FAX ❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT 31CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT CONTRACTOR NAME-Ff/,,,,f}5 LICENSE I�JMB�c ERvL LICENSE YPE BUS.LIC# % COMPANY NAMEE-MAIL ` FAX STREET ADDRESS CITY,STATE,ZI PHONE �6d S C�^rte e, >�i��c Ul zae ARCHITECT/ENGINEER NAME 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 � P cn� TOTAL VALUATION: DB,Y.' By my signature below,I certify to each of the following: I am the property owner or authorized agent t n the property owner's behalf. I have read this application and the information I have provided is correct. I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating to building construction. I authorize representatives of Cupertino to enter the above-identified property for inspection purposes. Signature of Applicant/Agent: Date: SUPPLEMENTAL INFORMATION RE IREDu ` USE OPILY � '��"• � �U�IEIi.THIUCOU�ITER�51•'�� g n } + n� i4 r MEPMiscApp_2011.doc revised 06/21/11 CITY OF CUPERTINO FEE ESTIMATOR-BUILDING DIVISION ADDRESS: 10721 JOHNSON AVE DATE: 10/28/2013 REVIEWED BY: MELISSA APN: 375 31 054 BP#: 13100156 'VALUATION: $8,000 *PERMIT TYPE: Electrical Permit PLAN CHECK TYPE: Alteration /Addition/ Repair --TPRIMARY PENMIT TY ON 1 REAP14 USE: SFD or Duplex PERMIT TYPE: WORK TEMPORARY POWER PERMIT SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Temporary Power 1ERT<200 100 Amps $47 TOTALS: $47.00 tt.en t'&�n('Jtc c'k Phinrh 1't�rrr C'h�.ct, Elec.Plan Check 0.0 hrs $0.00 Elec.Permit Fee: IEPERMIT O,ken af�a t2 Ir�'��_ Oti;cf`Plun21;Ir�s`� Other Elec.Insp. 0.0 hrs $47.00 tle� �. Ir, p. 1�e Phrrrth. lusp. Ie , Flec. hop, 1"v NOTE:This estimate does not include fees due to other Departments('tie.Planning,Public Works,Fire,Sanitary Sewer District,School District,etc). These fees are based on the prelimina information available and are only an estimate. Contact the De t or addn'l info, FEE ITEMS (Fee Resolution 11-053 Eff 7/1/131 FEE QTY/FEE MISC ITEMS Plant Chcxk 1 Fc: Suppl. PC:'Fcc PME Plan Check: $0.00 Permit F Esc Srtppl. hasp Fee PME Unit Fee: $47.00 PME Permit Fee: $47.00 Ct)it,SlrnC`ttOYI 1 rrr: Administrative Fee: 1ADMIN $44.00 Work Without Permit? 0 Yes Q No $0.00 �Idvanccd Planning,Pecs: Travel Documentation Fee: 1TRAVDOC $47.00 Strong Motion Fee: IBSEISMICR $0.80 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $1.00 SUBTOTALS: $186.80 $0.00 TOTAL FEE.' $186.80 Revised: 10/01/2013