14030178 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10708 JOHANSEN DR CONTRACTOR:GRAND NEST PERMIT NO: 14030178
CONSTRUCTION
OWNER'S NAME: TAO XIONG 13428 CHRISTINE DR DATE ISSUED:03/31/2014
OWNER'S PHONE: 4087718573 SARATOGA,CA 95070 PHONE NO:(408)891-8059
t ---- LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL COMMERCIAL
� N INSTALL TEMPORARY POWER POLE
License Class 6
Lic.# !
Contractor /,.,$2 JVA(IV-0 a! j �� 2121120V c_
I hereby affirm I/ ythat 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
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:37536003 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 YS 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 sav 180 S FRO 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 3
granting of this permit. Additionally,the applicant understands and will compl FE7�Date:
with all non-point source regulations per the Cupertino Municipal Code,Section
9 18.
,,�� G RE-ROOFS:
Signature Date 1 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
inspection.
❑ OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of Signature of Applicant: Date:
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 25505,25533,and 25534. j f
Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agent: Date: J `�
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
Compensation laws of California. If,after making this certificate of exemption,I CONSTRUCTION LENDING 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
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION O
E AVENUE•CUPERTINO, CA 95014-3255
(408) TORR
(408) 777-3228•FAX(408)777-3333•buildinaCa cupertino.org
CU P:EATt H o MISC
❑
PLUMBING
/ ❑MECHANICAL ELECTRICAL ❑MISCELLANEOUS
PROJECT ADDRESS/O�CX 70/An� Dy, IAPN,
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OWNERNAME ! �D \/T.a/I/ PHONE,9;C --/?1 k1?31
E-MAIL
STREET ADDRESS !�/v��0/\✓Q(�j�`'p/R 0r. CITY, STATE,ZIP. I' tit f r'f I no-,
CONTACT NAME j�,�/ T�`]/�e� PHONE E-MAII
STREET ADDRESS CITY,STATE,ZIP FAX
❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT
rk CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT
CONTRACTORNAME ��I1TA� J/li�Il LICENSENUMBER 96ST1 LICENSE TYPE BUS.LIC#
M
CONIPANYNAE(4 V D -4� C0�7RLkT3 E-MAIL /v T FAX
STREET ADDRESS CITY,STATE ZIP PHONE
ARCHTTECT/ENGINEERNAMELICENSENUMBER f
-� BUS.LIC#
COWANYNAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF ❑SFD or DUPLEX ❑ MULTI•FAMTLYPROJECT IN WI DLAND [3 YES PROJECT IN ❑YES rlSICHLER
THE BLDG AN ❑YES
BUILDING. ElCOMMERCIAL URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑NO HOME? ❑ NO
DESCRIPTION OF WORK
IAR
R, agni
TOTAL VALUATION: zoo ,�� tom,,
By my signature below,I certify to each of the following: I am the property owner or authorize r s behalf. e rea
application and the information I have provided is correct. I have read the Description of W and verify it is accurate. y with all applicable local
ordinances and state lavas relating to building construction. I authorize representatives of Cupertino to enter the abov -identified property for inspection purposes.
Signature of Applicant/Agent: Dat'. / Iq
SUPPLEMENTAL INFORMA QUIRED
_BURNS R=TH)<GOLZiTJ R
�FLES
v -
�
� ZARG
�e"£315"M3 TO
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MEPMiscApp_2011.doc revised 06/21/11
CITY OF CUPERTINO
FEE ESTIMATOR-BUILDING DIVISION
ADDRESS: 10708 JOHANSEN DR DATE: 03/31/2014 REVIEWED BY: MELISSA
APN: 375 36 033 BP#: 'VALUATION: $200
*PERMIT TYPE: Electrical Permit PLAN CHECK TYPE: Alteration/Addition / Repair
PRIMARY PENTAMATION
USE: SFD or Duplex F I PERMIT TYPE: 1 REAP1
WORK INSTALL TEMPORARY POWER POLE
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Temporary Power 1ERT<200 100 Amps $47
TOTALS: $47.00
� 1
Wh,< , I�'lon, t hrolh, Plan t::'/reokElec.Plan Check 0.0 I hrs $0.00
14"'c:h. 7'F>rtrrrr I'c>e: Ph rnty.Permit Fee. Elec.Permit Fee: IEPERMIT
Other Plumb Ins), Other Elea Insp. Fo.0 hrs $47.00
9hzt. Itiah. 1'-,�r,. Pharr. lisp. Fee 1�7e(,Imp,F"'T,
NOTE:This estimate does not include fees due to other Departments('tie.Planning,Public Works,Fire,Sanitary Sewer District,School
District,etc . Thesefees 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 E•ff. 711113) FEE QTY/FEE MISC ITEMS
Plan Check j�,CC:
S,P,PL PC,17 e!'
PME Plan Check: $0.00
1'c:°r,rrit f'"ec:
Su 11 t. Crt.ti,= 1 ee
PME Unit Fee: $47.00
PME Permit Fee: $47.00
C onslrll(iion KIX., L
Administrative Fee: IADMIN $44.00
Work Without Permit? ® Yes 0 No $0.00
Travel Documentation Fee: ITRAVDOC $47.00
Strong Motion Fee: 1BSEISIIIICR $0.50 Select an Administrative Item
BldgStds Commission.Fee: IBCBSC $1.00
$186.501 $0.00 TOTAL FEE: $186.50
Revised: 01/15/2014