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12080316 CITY OF CUPERTINO BUILDING PERMIT BILI LDING.UID RF.SS: 10610STANTAUAVE CO\1'RACI'OR:GREENTAIYO INC PERMITNO: 12080316 OWNI.R'S NAME: PRIGGE ROBERT E AND MASAMI DATE ISSUED:08/302012 OWNER'S PIIONE: 6507961790 IIALF MOON BAY,CA 94019 PHONE NO:(650)7964790 r^' ❑` LICENSED CON'rRACI'oRDECLARATION' BUILDING PERD ( 11T INFO: BLDG (_ ELECT r PLUNIB _I License Class Lic.M u V 3 � 8 � MECH r RESIDENTIAL r� CODIMERCIAL r Contmcto Date I hereby affirm that I am licensed under the provisions of C apmr 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. hereby affirm under penalty of perjury one of the following two declarations: I have and will maintain a cenificme 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:37537012.00 Occupancy Type: APPLICAN r CERTIFICATION' I certify that I have read this application and state that the above information is correct.l agree to comply with all city and county ordinances and state lows relating PERMIT EXPIRES IF WORK IS NOT STARTED to building constriiction,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 ofCupeninoagainst liabilities,judgments, 180 DAYS FRO —C-A.( LED 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-point source regulations per the Cupertino Municipal Code,Section Issued [if: Date: 9.18. c� r-�^ Signature - — Date U 2 -- RE-ROOFS: ❑ OWNER-BUILDER DECLARATION 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 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 work,and the structure is not intended or offered for sale(Scc.7044, Business&Professions Code) 1,as owner of the property,am exclusively contracting with licensed commenns to ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER consumer the project(Sec.7044,Business&Professions Code). 1 hereby affirm under penalty of perjury one of the follmling three ILVLARDOUS MATERIAI S 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 Ilealth& performance of the work for which this permit is issued Safety Code,Section 25532(n)should 1 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 tire Labor Code,for the performance of the work for which this contaminants its 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 Ilealth&Safety Code,Sections 25505,25533,and 25534. not employ any person in any manner so as to become subject to the Worker's On tMa thorized n t: Compensation laws of California. If,after making this cenificate of exemption,I Date: 8 �Q )2— become 2— 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. CONS UCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of work's A PPLICAN7'CERTIFICATION for which this permit is issued(Sec.3097,Civ C.) I certify that I have read this application and state that the above information is Lender's Name correct.I agree to comply with all city and county ordinances and state Ions relating to building construction,mid hereby authorize representatives of this city to enter Lender's Address upon the above mentioned property for inspection purposes.(Ale)agree to save indemnify and keep harmless the City of Cupertino against liabilities.judgments, costs,and expenses which may accrue against said City in consequence of the ARCIIITECI"S DECLARATION 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 Date CITY OF CUPERTINO FEE ESTIMATOR - BUILDING DIVISION ADDRESS: 10610 S TANTAU AVE DATE: 09/30/2012 REVIEWED BY: Sylvia APN: BP#: 'VALUATION: $400 *PERn1IT TYPE: Building Permit PLAN CIIECK TYPE: Alteration / Repair PRIMARY SFD or Duplex PENTAMATION 1REAP14 USE: PERMIT TYPE: WORK INSTALL TEMP POWER SCOPE Afech. Man Check Plumb. Plan Check Elec. Plan Check 0.0 hrs $0.00 Afech. Permit Fee. Phnnh. Permit Fee: Elec. Permit Fee: IEPERAHT Other Plumb Insp. Other Elec. Insp. 0.0 hrs $45.00 othup.,%fech. I MP ,Mach./lisp.Fore: Phunb. Lisp.Fee: Elce.Insp. Fee: NOTE: This estimate does not includejees due to other Departments(i.e. Planting, Public Works, Fire,Sanitary Sewer District,School District,etc.). These fees are based air the prelintinan information available and are on1v an estimate. Contact the Dept for addn'I info. FEE ITEMS (Fee Resolution 11-053 E/C WRI1) FEE QTY/FEE MISC ITEMS Plan Check Fee: $0.00 = amps Electrical Suppl. PC Fee: 0 Reg. Q OT 0.0 hrs $0.00 $45.00 IERT<200 I Temporary Power PME Plan Check: $0.00 Permit Fee: $0.00 Suppl. Insp. Fee Q Reg. Q OT 0,0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $45.00 Construction Tar: Administrative Fee: IADAHN $42.00 O Work Without Permit? O Yes (F) No $0.00 (F) Advanced Planning Fee: $0.00 Select Non-Residential Q Travel Documentation Pee: 1TRAItDOC $45.00 777 A Building.or'Structure O Strong Motion Fee: IBSEISAYCR $0.50 Select an Administrative Item BldgStds Commission Pee: IRCRSC $1.00 SUBTOTALS: 1 $133.50 $45.001 TOTAL FEE: $178.50 Revised: 07/01/2012 i 2c:�)C o;,0 GENERAL PERMIT APPLICATION E Eu COMMUNITY DclELOPMENT DEPAR T A.1ENT• BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 9501;-3255 IIC CUPERTINO (408) 777-3228 • FAX (408)7777-3333 • buildinc(acuDerino.DrD ❑?LLMBLNC ❑*.CCf:4MCAL DELECnucA- ❑NUSC-L ANEOUS =Ror5;.+�DR35 1060 0 - © -A vQ I A..FN ME �/-- X OWNER NA STRZ.-IADDRESS I C-1'. STA-L7V D / FAX CII idz COMAS NAME FHONE I Mpn STftET ADDRESS C1 i f,SCAT; c-P. FAX ❑ Owvm ❑ OWNER-Bt!✓^ER ❑ OWN:a AC1'i ❑ CJONTRA=R ❑commACTOR AGENT ❑ ARC== ❑ Dir_Grn ❑ �tAN; CONiAA�OR NAME (�T YA'lIl llCviSE NIR.L'^ZQ�3 O I LIC\Sc T:'PE 'JQ I BUS.LIC 9 .\T CDMPANAl+[E FAX P ��^+� L-7'ADDR=55 I C1 10, C.Y.STATE,E� '�/� FRO'•EC3511V/ _I� B ARCST_CT,7iG1N=- NAME I LICL SE N1il OER 1"1 I BUS.!JC.4 CONLTANYNAME' I E-MAE. FAX STF-E-T/DDR-SS C!".STATE ZIP MON. USE OF ❑57 a DUPLjC ❑ NN1Tf-FAMIlY PROTECT IN WILOLAHO O YS PRGIECi IJ 11 zI IS TL-BLDG AN ❑ YES SU ItG: CoM .CIAL bIi AN Nf-cRFACE AAA NO '0.-ZONE ❑NO pCvRi HOMc. ❑No DESC-ti IM0N OF WORMY TOTAL VALUATiGN: a I RECEI�- BY: - VC C ' 3y my stg:axre below,I eT;-y to each of the foPow:=g: I am'te pmperl owDer or acChoriaod agent to act on the pmpery owner's behaif. I have read tills application and the in or ondon I have pm ided is cor_cL I'ave re d the Desaipdon of Work aad ve:iiy it is==:e. I agree lo comply widb all applicable local ordiaaic:s and sate laws relating to building censyncdon. I ;ho. -repmsntatives of Cuocmzn:n^rer the aaabbovT. nu5e3 pro a for inspection pu:peses. Signatu.-e o`Apolicant/Ageut Q. Dz-p: (/ 2 SUPPLEMEt IT? ORM_AT!O REQUR"D ELSE ONLY y -THE{OUNTER ❑ EXPRESS V ❑ STANDARD L ❑ LARGE ❑ MAJOR IaPc?:LFsc??D_i011.doc ravued 06121111