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12030057 CITY OF CUPERTINO BUILDING PERMIT BUILI/INGAIIDRESS: 102I3STANTAVAVE CONTRACTOR:PROVISION PERMIT NO: 12030057 DEVELOPMENT,INC. OWNER'S NAME: VIRAY PROPERTIES LLC 1288 KIFER RD STE 217 DATE ISSUED:03/1 220 1 2 O\YNER'S PHONE: 4089048614 SUNN)'VAI.E.CA 941186 PHONE NO:(4118)21511991 �_ LICENSED f..ONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG r r ELECT PLUMB r License Class Lic.k R 751 , PIECH r RESIDENTIAL r' COMMERCIAL r Corrector�71�\V� Fly Dai��'2-� 1 hereby affirm that 1 am licensed ander the provisions of Chapter 9 30R DESCRIPTION:INSTALL TEbIP POWER POLE (commencing with Section 70141)of Division 3 of the Business\Professions Code and that my license is in full force and effect. 1 hereby affirm under penalty of Perjury one of the following two declarations: I have and will maiumin a cenificate 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. (have and will mainmin Worker's Compensation Insurance,as provided for by Sq.Ft Floor Area: Valuation:5420 Section 3700 of(he LaborCode.for the performance of dna work for which this permit is issued. APN Number:3750703'.00 Occupancy Type: APPLICANT CERTIFICATION I certify that l have read this application mid state that the above information is correct, I agree to comply with ail city and county ordinances mid state laws relating PERMIT EXPIRES [F WORK IS NOT STARTED to building construction,and hereby authorize representatives of this city m 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, I80 DAYS FROM LAST CALLED INSPECTION. costs,and expenses whichmay accrue against said City in consequence of the granting of this permit. Additionally,the applicant underslmmds and will comply with all non-point source regulatiahs per the Cupertino Municipal Code,Sectio Issued Y•: Date:�� 9.13. Sienature Date \2� el RE-ROOFS: ❑ OWNER-RIIILOER DECLARATION All roofs shall be inspected prior to any roofing material being installed Ira roof is installed without first obtaining am inspection,1 agree to remove all new materials for 1 hereby affirm that P run exempt front the Contractor's License Law for one of inspection. the following two reasons: 1,as owner of the property,or ry employees with wages as their sole compensation. Signature of Applicant: Date: will do the work,mid the suucmre is no intended or offered for sale(Sec.7044, Business&Professions Code) P,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 ander penalty of perjury one of the following three HAZARDOUS MATERIALS DISCLOSURE declarations: 1 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 R Safety Code,Sections 255115,25533,and 25534. 1 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(his Permit is issued. Safety Code.Section 25532(a)should I store or handle hazardous material. I have mid will maintain Worker's Compensation Insurance,as provided for by Additionally,should 1 use equipmen(or devices which emit hazardous air Section 3700 of the Labor Code,for(lie perfomance of die work for which this contaminants as defined by the Bay Area Air Quality Management District I will permit is issued. maintain compliance with(he Cupertino Municipal Code,Chapter 9.12 and the Health&Safety Code,Sections 251,05,25533,and 25534. 1 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 Ow er or authorized agent: Compensation laws ofCalifomia. If,atter nicking this cenificate of exemption,I "3nte: '. \-2;A 7 become subject to the Worker's Compensation provisions of the Labor Code,I must y for(hwidh comply with such provisions or this recruit shape be deemed revoked. CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of work's APPLICANT CERTIFICATION for which this permit is issued(See.3097,Civ C.) I cenify Him I have read(his application and state that die above information is Lender's Name correct.I agree to comply with all city and county ordinances and state laws relating to building construction,mid hereby authorize representatives of this cit to enter Lender's Address upon the above mentioned property for inspection purposes.(We)agree to save indemnify and keep hatless the City of Cupertino against liabilities,judgments, costs,and expenses which may aceme against said City in consequence of the ARCHITECT'S DECLARATION granting of dais petit.Additionally,the applicant understands and will comply I understand my plans shall he used as public records. with all non-point source regulations per the Cupenino Municipal Code,Section 9.13. Licensed Professional Sienature Date CITY OF CUPERTINO 6 ITEMS OF 6 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN . . . . . . . . : 37507032 . 00 DATE ISSUED. . . . . . . : 03/12/2012 RECEIPT # . . . . . . . . . : BS000016252 REFERENCE ID # . . . : 12030057 SITE ADDRESS . . . . . : 10218 S TANTAU AVE SUBDIVISION . . . . . . . CITY . . . . . . . . . . . . . : CUPERTINO IMPACT AREA . . . . . . . OWNER . . . . . . . . . . . . : VIRAY PROPERTIES LLC ADDRESS . . . . . . . . . . : 1100 ZAMORA CT CITY/STATE/ZIP . . . : MILPITAS, CA 95035-3427 RECEIVED FROM . . . . : QIUANG D NGUYEN CONTRACTOR . . . . . . . : JOHN HA LIC # 29054 COMPANY . . . . . . . . . . : PROVISION DEVELOPMENT, INC. ADDRESS . . . . . . . . . . : 1288 KIFER RD STE 207 CITY/STATE/ZIP . . . : SUNNYVALE, CA 94086 TELEPHONE . . . . . . . . : (408) 245-0991 FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- --- 1ADMIN HOURS 1 .00 41 .00 0 .00 41 .00 0 .00 1BCBSC VALUATION 420 .00 1 .00 0 .00 1 .00 0 .00 1BSEISMICR VALUATION 420 .00 0 .50 0.00 0 .50 0 .00 IEPERMITFE FLAT RATE 1 .00 44 .00 0.00 44 .00 0 .00 1ERT<200 UNITS 1 .00 44 .00 0.00 44 .00 0 .00 1TRAVDOC FLAT RATE 1 .00 44 .00 0. 00 44 .00 0 .00 ---------- ---- ----- --------- ---------- TOTAL -------- TOTAL PERMIT 174 .50 0 . 00 174 . 50 0 . 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CREDIT CARD 174 . 50 VISA --------------- TOTAL RECEIPT 174 . 50 VOICE ID DESCRIPTION VOICE ID DESCRIPTION ----- ---------------------------- - -------- 402 TEMPORARY POWER Revised: 1/1912012 GENERAL PERMIT APPLICATION M E P COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION ' 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 M I /� CUPERTINO (408)m (CD -3228 • FAX(408)777-3333• buildinccuoerdno.ora /v' ❑FLUNKING El MECHANICAL RULE=CAL VIMISdLLANEOUS FRCIECTADO l VV ^i ^ � 0-703 OWNERNAME FHO ^ E STTA1DOSS ,yTTFAX a nbQOT CONTACT NAME HOEa} (koS q1 —0!6d C_'1 r`69 : ITRZ SCl-ff Y SG�AVIffi �'lUD FSO —Z�'IS'��( ❑ow '❑ OwNER-IRJBDER ❑ OWNER AGENT V+ MN RACtOR ❑CONTRAnnRAGENr ❑ ARmVIELT ❑FNOuNEIDt ❑ DEvELoPER ❑ TENAN: CONTRACTOR N [10E SESW�EA R I LICEt TYPE I BUS.LIC0 CON ANYNAbm E-MAIL 17 . 2-" C - 031 ITR=An(REss 9 '/L r1 / an'.srA>E. / G ((� p1 U'�` P I ARCRTECDENGINEEA NAME BUS.LIC p CONVANY NAME' E�?S p Fa�xc STREET,ADD = I Cm,STATE.ZT (,f Og Pa O - �i4�- dg41 USE OF O sFD w Dup= I§7-mu-n-FArm.Y I PROIFLr IN WI DU.W ❑ YEs I PROJECT N ❑YES LIrxe BLoe AN ❑ YES BUILDING. CAM ERCIAL URBAN B.TENFACE AREA NO FLOOD ZONE O E'aBF]t HO.NEf ❑NO DESCRIPTION OF WORK — ert..tii TOTAL VALUATION: �J n I RECE[VED BY: By my sigtraose below,I catify m each of the fuf lowing I am the property owns cr antorriud agent to ac,on the propert awoer's behalf. I h r esd- s application and the information I have provided is correct have read the Description of Work and verify it is accurate. I agree m comply wide all applicable local ordinances and amen laws relating to building construction.`[audacriae representatives of Cuperno to enter the above-iirafied Tppery for inspection pu@mcs. Siepannc ofAppliemr/Agenn Duns: , �/(/ / -z- SUPPLE' SUPPL.E'2,=1 AL INFORNfATTON REQUIRED OFFICE SE ONLY u OVER-THE-COUNTER ❑ EXPRESS Y V ❑ S V(DARD U Z ❑ LUtCE S c ❑ MAJOR MEPY4c4pp 2011.dac revised 06/21/11