12060142 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10310 MORETTI DR CONTRACTOR:AVA CONSTRUCTION PERMIT NO: 12060142
OWNER'SNAME: MOI-ISENIALILI 20689 FORGE WAY UNIT 202 DATE ISSUED:0625/2012
OWNER'S PHONE: 4088490408 CUPERTINO,CA 95014 PHONE NO:(408)387-0999
LICENSED CONTRACTOR'S DECLARATION. BUILDING PERMIT INFO: BLDG r ELECT r PLUMB r
License Claes Lic,q �'�1 7 LI
/J �.,,I /7 MECH r RESIDENTIAL r COMMERCIAL r
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Contractor /_/f-tel d7C�S e��GOaie
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I hereby affirm that I am licensed under the provisions of Cbut pler 9 JOB DESCRIPTION: INSTALL TEMP POWER POLE
(commencing with Section 7000)of Division'3 of the Business&Professions
Code and that my license is in full force and effect.
1 hereby affirm under penally of perjury one of the following two declarations:
1 have and rill 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:$400
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:37515010.00 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 slate 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 FROM LAST CALLED INSPECTION.
costs,and expenses which may accrue against said City in consequence of the
granting of this permit. Additionally,the applicant understands and will comply /
with all non-points ur regulations per the Cupertino Municipal Code,Section Issued by: Date:
9.18. ��,��jj
Signature Date ir�2
RP:ROOFS:
❑ OWNER-BUILDER DECLARATION All roofs shall be inspected prior to any roofing material bcimg installed.If a roof is
installed without first obtaining an inspection.I agree to remove all new materials for
1 hereby affirm that I am exempt from the Contractor's License Law for one of inspection.
the following two reasons:
I,as owner of the property,or my employees with wages as their sole compensation, Signature of Applicant: Date:
will do the stork,and the structure is not intended or offered for sale(Sec.7044,
Business&Professions Code)
L,as owner of the property,am exclusively contracting with licensed contractors to AL1.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: 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&Safety Code,Sections 25505,25533,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 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 1 will
permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
!
I certify That in the performance of the work for which This permit is issued,I shall Health&Safety Code,Sections 25505,25533,and 25534.��
not employ any person in any manner so as to become subject to the Worker's own ym ori e f !razed agent•
Compensation laws of California. If,after making this certificate of exemption,I / �GT G7 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 hereby 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 slate 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 DECLARATIONcosts,and expenses which may accrue against said City in consequence of the
granting of this permit.Additionally,the applicant understands and will comply I understand my plans shall be used as public records.
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18. Licensed Professional
Signature Dale
L 0:5 1 CITY OF CUPERTINO
FEE ESTIMATOR- BUILDING DIVISION
ADDRESS, 0 moretti dr. II
DATE: 06/25/2012 REVIEWED BY: bobs.
APN: BP#: •VALUATION: $400
xPERMIT TYPE: Electrical Permit PLAN CHECK TYPE: Alteration/Addition / Repair
PRIMARY SFD or Duplex PENTAMATION 1REAP14
USE: PERMIT TYPE:
WORK install temp ower pole.
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BPFEES
Temporary Power 1ERT<200 100 Amps $44
TOTALS: $44.00
.11",h. r!n.;c'h"r Phn»h. lYun( hc,A Elec. Plan Check 0.0 1 hrs $0.00
�1.-n4. I' ,vuit Far: l'Inmh. 1Trnul F,t Elec. Permit Fee: 1E•PERMIT
Urher I hq h. lnal�_ lhhe, 1'lnrnL Imp. Other Elec. Insp. 0.0 hrs $44.00
h?,p. 1 co Phuuh. bnp. Frd: Fh'r Imp. 14 r•.
NOTE: This estimate does not include fees due to other Departments(i.e. 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 Det for addn'l info.
FEE ITEMS (/ee Resv6uion II-053 Ell. 711111) FEE QTY/FEE MISC ITEMS
Plan (-hr(k Pcc.
Nuppl, I'(' Fcc
PME Plan Check: $0.00
l',:rmil F,:r.-
Nn/pl, hup lrci,
PME Unit Fee: $44.00
PME Permit Fee: $44.00
(.'0)U/1 alion 7-11,c
Administrative Fee: (ADMIN $41.00
Work Without Permit? O Yes (j) No $0.00
,1'h"111(, 1/'/,11111in,t P-ces-
Travel Documentation Fee: /TRAVDOC $44.00
-S"01111 Motion l ec: IBSEISMICR $0.50 Select an Administrative Item
Bida Stds Commission Fee: IBCBSC $1.00
SUBTOTALS: $174.50 $0.001TOTAL FEE: $174.50
Revised: 06/30/2012
GENERAL'PERMIT APPLICATION M E P
COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION
10300 TORRE'AVENUE•CUPERTINO, CA 950143255 M I
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CUPERTINO (408)777-3228'• FAX(408)777-3333• buildinGCcDcuoertinO.DrD
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❑PLUIvBING Irff.CHAMCAL CIRICAL ONUSCELLkNEOUS
PROJECTADDRESS I at-iC .APNa O
k, PHONE
OWNER NAME b CA.`'�`\ V I E 1 Kft` cov � L(<'
STREET'ADDRESS � CSW CRY,STATE,ZIP / e r-n� F `-i�
CONTACT NAME P NE �E(� `� Cil.✓a-C l[.�'�(o U'L CW 6 7 C�
STREETADDRESS CITY,STATE, ZIP FAX
❑OWNER ❑ OwNFR.aUDDER ❑ OWNER AGENT M'COMMCIOR ❑CONTRACTOR AGENT ❑ xItaumCT ❑ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME v, u /J ICK CFNSENUMBEP %50LI@A'ETYPE BUS.LICA
COMPANY NAME 0. Cf.5 e
FAxi-o \
STREET ADDRESS•) 1 p r CITY.STALE.ZIP — r PHONE C
ARCHITECf/ENGINFER (NAME/ LICENSE NUMBER l BUS.T!C N
COMPANY NAME E.MAR FAX
STREEIAODRESS CRY,STATE,ZIP PHONE
USE OF AFITD.DUPLEX ❑ MULTWAMILY PROJECT IN WI DL ND ❑ YES PROJECT N ❑YES IS THE BLDG AN ❑ YES
.BUILDING: ❑ LLL COMMERCURBAN INTERFACE AREA ❑ NO FLOOD ZONE 0N ELCHLER HOME: El No
DESCRIPTION OF WORX
TOTAL VALUATION: I RECEIVED BY:
By my signature below,I certify to each of the fallowing: I em the property owner or authorized agent to act on the property owner's behalf. I have mad this
application and the information I have is correeL:f have tcrd the Description of Work and verify it is accurate. 1 agree m comply with all applicable local
ordinances and state laws relating mb,
ding etion. I authorize representatives of Cupertino to enter the above-idend5edproper+r Spec on pu0oses.
SigoaeueofApplicaot/Agene Dare: —�—/
SUPP AL'INFORMATION REQU= OFFICE USE ONLY
_Z1BVVE.R-THE-COUNTER
❑ EXPRESS
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❑ STANDARD
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❑ NWOR
A&Phruc:App_2011-doc revised 06121111