13010005 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: -10623 JOHANSEN DR CONTRACTOR:HSIEH T HAD PERMIT NO:13010005
OWNER'S NAME: WANG LIEH C TRUSTEE&ET AL 4150 OLD ADOBE RD DATE ISSUED:01/022013
OWNER'S PHONE: 4089971403 PALO ALTO,CA 94306 PHONE NO:(650)888-3030
❑ LICENSED CONTRACTOR'S DECLARATION 30B DESCRIPTION: RESIDENTIAL COMMERCIAL
License Class. Lic..# 0* 2' TEMP POWER POLE
Contractor 6 l$ r 2 ( Fla o Date e42 O
1 hereby affirm that 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:$500
I have and will maintain Worker's Compensation Insurance,as provided for by
Section 370,0 of the Labor Code,for the performance of the work for which this APN Number:37537058.00 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 WITHIN 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 F �CALLED INSPECTION.
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may aceme against said City in consequence of the Issued by:
Date:
granting of 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 // w - Datel//�13 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.
❑ - OWRATION
-- Signature of Applicant: Date:
I hereby affirm that am exempt from the Contractor's License Law for one of
the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
1,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). -
1,w owner of the property,am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE
construct theproject(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
1 have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sections
2255059 25533,and 25534.
Section 3700 of the Labor.Code,for the performance of the work for which this Owner or authorized agent: /` ` T /14�— Date: 2 )3
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 CONSTRUCTION LENDING AGENCY
Compensation laws of California. If,after making this certificate of exemption,I
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 haveread 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
CITY OF CUPERTINO
FEE ESTIMATOR-BUILDING DIVISION
13-ADDRESS: 10623 johansen dr DATE: 01/02/2013 REVIEWED BY: mendez
APN: I BP#: VALUATION: $500
*PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration/ Repair
PRIMARY SFD or Duplex PENTAMATION 1REAP14
USE: PERMIT TYPE:
WORK Temp power pole
SCOPE
;blec/r. /'!un Check Plumb. Plan Check Elec.Plan Check 0.0 hrs $0.00
Mech. Permit Fee: Plumb. Permit Fee; Elec.Permit Fee: IEPERMIT
Other,tfeeh.Insp. Other Plumb Insp.
Other Elec.Insp. 0.0 hrs $45.00
A•tcch, Insp.Fee: Plumb, Insp.Feer Elec. Insp. Fee-
NOTE. This estimate does not include fees due to other Departments(Le.Planning,Public Works,Fire,Sanitary Sewer District,School
District etc). These ees are based on the prethnina information available and are only an estimate. Contact the Dept for addn7 info.
FEE ITEMS (Fee Resolution 11-053 Eft 711112) FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.001 amps Electrical
Suppl.PC Fee. Q Reg: 0 OT 0.0 hrs $0.00 $45.00 IERT<200 Temporary Power
PME Plan Check: $0.00
Permit Fee: $0.00
Suppl. Insp.Fee-.0 Reg. 0 OT 0,0 I his $0.00
PME Unit Fee: $0.00
PME Permit Fee: $45.00
Construction Tax.
Administrative Fee: IADMIN $42.00 O
Work Without Permit? 0 Yes 0 No $0.00 0
Advanced Planning Fee: $0.00 Select a Non-Residential 0
Travel Documentation Fee: ITRA VDOC $45.00 1
Building or Structure 0�
Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item
Bldg Stds Commission Fee: 1BCBSC $1.00
¢i; r $133.50 $45.00 , TOTAL FEE:: $178.50
Revised: 10/01/2012
GENERAL PERMIT APPLICATION M E P
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION AQP
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 \ M '
CUPERTENO leD
(`08)777-3228-FAX(408)777-3333• buildinGcuoertino.orG �Q
SC
PLUMBING EINMCKANICAL ❑ELECTRICAL ❑MISCELLANEOUS
PAOIACTADDRFSs j D&. -6 1 aK5;e h Dr I V'P APN.Y
OWNERNAME i.`�'e 2 /W Q.]'�„ p PHO �C pC/7 E-MAIL
STREET ADDRESS I ob-416ieeN DYIV\ cm-sTATB,2@C g/y i FAX
C. LI
CONTACT NAME PHONE E-MAB.
STREET ADDRESS CTTY,STATE, ZP FAX
❑ OWNFR ❑ OWNER-BUDDER ❑ OwNERAGENI' ❑ CONTRACrOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTORNAMB /f 7-, J�A O LICENSENUMBER LICENSE TYPE BUS.UC0
COMPANY NAME r� / t/, B-MAIL FAX
STREET ADDRESS CITY,STATE ZIP PHONE
ARCHTTECLDiGINEER NAME LICENSE NUMBER BUS.LIC 0
COMPANY HAMS' E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF ❑sm.DUPLEx ❑ MULTI-FAMD.Y PROJECT DJ WnDLAND ❑ YES PROJECT IN ❑YES ISTHEBLDGAN ❑ YES
BUILDING: CONJAERCLAL URBAN DJTERPACE AREA I3 NO FLOOD ZONE ❑NO EICHLER HOME? 0 NO
DESCR1PnONOF WORK aM ROW4ey
TOTAL VALUATION: + D RECEIVED BY:
By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on the proalf. I bavc read this
application and the information I have provided is ootrect I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating to buil ' g construed Ian orize representatives of Cupertino to enter the above-identifiedproperty for inspection pui$oses.
Signamm ofApplicanUAgent Date:
SUPPLEMENTAL INFORMATION REQUIRED OFFICE USE ONLY
OVER-THE-COUNTER
Y ❑ EXPRESS
u
❑ STANDARD
U
❑ LARGE
❑ MAJOR
MEPMucApp_201I-doc revised 06/27111