15110056rZ
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10676 CARVER DR
CONTRACTOR: TQ CONSTRUCTION
PERMIT NO: 15110056
OWNER'S NAME:.GERALD LI Ni �_ /1
U(ti (L jq\ LL
3044 KENTRIDGE DR
DATE ISSUED: 11/10/2015
OWN R'S PHONE: 7r -.7::,t
SAN JOSE, CA 95133
PHONE NO: (408) 849-1715
LICENSED CONTRACTOR'S DECLARATION
JOB DESCRIPTION: RESIDENTIAL COMMERCIAL
License Clash Lie. # .�
INSTALL TEMP POWER (100 AMP)
Contractors—' r ate
I hereby affirm that I am licensed under the provisions of hap t r9
(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
p rformanoe of the work forwhich this permit is issued.
Sq. Ft Floor Area:
Valuation: $400
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: 37532015.00
Occupancy Type:
permit is issued.
APPLICANT CERTIFICATION
I certify that Ihave 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
WITIIIN 180 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 DAYS FROM 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
Issued by: v`-� Date: << < b J
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:
Signature..' Date
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
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'struoture isnot intended or offered for sale (Sec.7044,
Business & Professions Code)
1, 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(x) 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, 3, nd 534.
Section 3700 of the Labor Code, for the performance of the work for which this
Owner or authorized ag nt: Date: It/�r� lir
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.
i
SignatureDate
CUPERTINO
Ur
GENERAL PERMIT APPLICATION
COMMUNI TY DEVELOPMENT DEPARTMENT - BUILDING DIVISION
10300 T ORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228 • FAX (408) 777-3333 • buildin06O OUDe]iinO.Orq
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By my signature below, I certify to each of the following: I am the property owDer or au`thwized agent to act on the prope ty owner's behalf. I hive read this
application and the in.fonnation I have provided is
correct. I have read the Description of Wark and verify itis accurate. I agree to comply with all applicable local
ordiiances and state laws relatin.0 to building construction. I authorize representatives of Cupertino to enter the above -identified property for inspection purposes.
SigmatureofAuplicant/Agent:��
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NffPM17sc,4Dp_2011.doc revised 06/21/11
CITY OF CUPERTINO
FEE ESTIMATOR — BUILDING DIVISION
igADDRESS: 10676 Carver Dr
FEE ID
DATE: 11/10/2016
REVIEWED BY: Phuong
APN: 375-32-015
1 BP#:
*VALUATION: 1$400
*PERMIT TYPE: Electrical Permit
I ERT<200
PLAN CHECK TYPE: Alteration / Addition / Repair
PRIMARYPENTAMATION
. SFD or Duplex
USE:
Amps
IREAP14
PERMIT TYPE: A
WORK
Install temp power (100 amp)
SCOPE
APPLIANCE / EQUIP TYPE
FEE ID
QTY/FEE
QTY
UNITS
BP FEES
Temporary Power
I ERT<200
100
Amps
$48
per mil pec"
PME Unit Fee:
$48.00
PME Permit Fee:
$48.00
(.1
"onstruction
Administrative Fee: IADAffN
$45.00
Work Without Permit? 0 Yes (D No
$0.00
TOTALS:
A
Travel Documentation Fee: I TRA VDOC
$48.001
Strong Motion Fee: IBSEISMICR
NOTE. This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School
Divir;rt air ) Thovo tape aro havpd on the nrPfimh7ary information availahlp and are nn1v an estimate. Contact the Dent for addn'l info.
FEE ITEMS (Lee Resolution 1.1-053 G,ff. 7/11131
FEE
QTY/FEE
MISC ITEMS
PNffi Plan Check:
$0.00
per mil pec"
PME Unit Fee:
$48.00
PME Permit Fee:
$48.00
(.1
"onstruction
Administrative Fee: IADAffN
$45.00
Work Without Permit? 0 Yes (D No
$0.00
A
Travel Documentation Fee: I TRA VDOC
$48.00
Strong Motion Fee: IBSEISMICR
$0.50
Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC
$1.00
:SUBTOTALS:,
$190.50
$0.00 TOTAL FEE:
$190.50
Revised: 10/01/2015