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11040158
CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 20557 BLOSSOM LN CONTRACTOR:RYAN HU PERMIT NO: 11040158 OWNER'S NAME: KEN HSIEH&JEAN LAI 401 S NORFOLK ST DATE ISSUED:04/22/2011 OWNER'S PHONE: 4089305181 SAN MATEO,CA 94401 PHONE NO:(650)343-8038 C� LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ELECT I— PLUMB License Class Lic.# MECH F RESIDENTIAL COMMERCIAL Contractor V Date I hereby affirm that m licensed under the provisi sof Chapter 9 JOB DESCRIPTION: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. 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 /6J/ 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:$850 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:35918033.00 Occupancy Type: APPLICANT CERTIFICATION / I certify that I have read this application and state that the above informati4cs,1 correct.I agree to comply with all city and county ordinances and state 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-pregulations pert Cupertino Municipal Code,Section Issued by: Date: 9.18. Signature Date 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 1 hereby affirm that I am exempt from the Contractor's License Law for one of inspection. the following two reasons: 1,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(Sec.7044, Business&Professions Code) 1,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 under penalty of perjury one of the following three HAZARDOUS MATERIALS DISCLOSURE declarations: I have read the hazardous materials requirements under Chapter 6.95 of the 1 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 I will permit is issued. maintain com 'ance with the Cupertino Municipal Code,Chapter 9.12 and the Health&S ety Code,Sections 25 5,25533,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 Owner r h rized agent- Compensation laws of California. If,after making this certificate of exemption,I 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"wrk's APPLICANT CERTIFICATION for which this permit is issued(Sec.3097,Civ C.) 1 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 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 DECLARATION cc � and expenses which may accrue against said City in consequence of the € ig of this permit.Additionally,the applicant understands and will comply I understand my plans shall be used as public records. WILH all non-point source regulations per the Cupertino Municipal Code,Section 9.18. Licensed Professional Signature Date CITY OF CUPERTINO 6 ITEMS OF 6 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN . . . . . . . . : 35918033 .00 DATE ISSUED. . . . . . . : 04/22/2011 RECEIPT #. . . . . . . . . : BS000013265 REFERENCE ID # 11040158 SITE ADDRESS . . . . . : 20557 BLOSSOM LN SUBDIVISION . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . OWNER KEN HSIEH & JEAN LAI ADDRESS . . . . . . . . . . : 581 JAY ST CITY/STATE/ZIP . . . : LOS ALTOS, CA 94022 RECEIVED FROM . . . . : RYAN C HU CONTRACTOR . . . . . . . : RYAN C HU LIC # 25425 COMPANY . . . . . . . . . . : RYAN HU ADDRESS . . . . . . . . . . : 401 S NORFOLK ST CITY/STATE/ZIP . . . : SAN MATEO, CA 94401 TELEPHONE . . . . . . . . : (650) 343-8038 FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- ---------- -ADMIN HOURS 0.50 39. 00 0. 00 39.00 0. 00 1BCBSC VALUATION 850 .00 1. 00 0. 00 1.00 0. 00 1BSEISMICR VALUATION 850 .00 0.50 0. 00 0 .50 0. 00 1EPERMITFE FLAT RATE 1 .00 42 .00 0. 00 42 .00 0. 00 1ERT<200 UNITS 1. 00 42. 00 0. 00 42. 00 0.00 1TRAVDOC FLAT RATE 1.00 42. 00 0.00 42 .00 0.00 ---------- ---------- ---------- ---------- TOTAL PERMIT 166.50 0. 00 166 .50 0. 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CHECK 166.50 #4557 --------------- TOTAL RECEIPT 166.50 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 402 TEMPORARY POWER CITY OF CUPERTINO FEE ESTIMATOR-BUILDING DIVISION ADDRESS: 20557 blossom lane DATE: 04/22/2011 REVIEWED BY: bobs. APN: BP#: `"VALUATION: $850 R'PERMIT TYPE: Electrical Permit PLAN CHECK TYPE: Alteration /Addition/ Repair PRIMARY SFD or DuplexPENTAMATION 1 REAP14 USE: PERMIT TYPE: WORK install temp power pole SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Temporary Power 1ERT<200 100 Amps $42 TOTALS: $42.00 Elec.Plan Check 0.0 1 hrs $0.00 Elec.Permit Fee: IEPERMIT LjOther Elec.Insp. 0.0 hrs $42.00 NOTE: These ees are based on the prelindnary in ormation available and are only an estimate. Contact the De t or addn 7 info, FEE ITEMS (Fee Resolution 09-051 F- T 1. 10) FEE QTY/FEE MISC ITEMS PME Plan Check: $0.00 PME Unit Fee: $42.00 PME Permit Fee: $42.00 Work Without Permit? 0 Yes No $0.00 Travel Documentation Fee: ITRA VDOC $42.00 Strong Motion Fee: IBSEISMICR $0.50 0.5 hrs Admin./Clerical Fee Bldg Stds Commission Fee: 1BCBSC $1.00 $39.00 ]ADMIN SUBTOTALS; $127.50 $39.00 TOTAL FEE: 1 $166.50 Revised: 04/01/2011 Building Department City Of Cupertino LEI 10300 Torre Avenue Cupertino, CA 95014-3255 Telephone: 408-777-3228 U P E RT I N O Fax: 408-777-3333 CONTRACTOR/ SUBCONTRACTOR LIST JOB ADDRESS: PERMIT# D OWNER'S NAME: PHONE # 7 GENERAL CONTRACTOR: BUSINESS LI ENSE# z Z ADDRES CITY/ZIPCODE. *Our municipal code requires all businessesWorking in the city to have a City of Cupertino usiness license. NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE GENERAL CONTRACTOR AND ALL SUBCONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE. I am not using any subcontractors: Signature Date Please check applicable subcontractors and complete the following information: 6/ SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets & Millwork Cement Finishing Electrical Excavation Fencing Flooring / Carpeting Linoleum / Wood Glass / Glazing Heating Insulation Landscaping Lathing Masonry Painting/Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile , O ner/Contr "tor Signature Date GENERAL PERMIT APPLICATION MEP COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 (408)777-3228• FAX(408)777-3333•building(Scupertino.org MISC CUFEFtTINC3 ❑PLUMBING ❑MECHANICCAAL " ELECTRICAL ❑MISCELLANEOUS ISSCCELLANEOUS REAPN PROJECT ADDSS'7/f? # G V 0 _2� OWNER NAME �—J _ f` PHONE i IO 20 1 .�5/ MAJL STREET ADDRESSZO Y 'x I'�/©�( /S /r CITY,STA EW) Z�Lj FAX CONTACT NAME � j(/ A'\/VE- ai C PHO &e w STREET ADDRESS / z?4IJ16-1 1 i' A+ t j ❑OWNER ❑ OWNER-BUILDER ❑ OWNERAGENT VCONTRACTOP ❑CONTRACTORAGENT ❑ ARCHrrECT ❑ENGINEER ❑ DEVELOPER ❑TENANT` CONTRACTOR NAME % 6 LICENSE NUMB LICEN E BUS. # Fes( COMPANY NAMEP�1(� E-MAIL F STREET ADDRESS c// M"V� �/ CITY,ST �� C� ARCHITEC IENGINEER NAME LICENSE NUMBER BUS. C# COMPANY NAME E-NIAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE TSE OF SFD or Duplex ❑ Multi-Family PROJECT IN WILDLAND PROJECT IN STRUCTURE: C3 COrIlIrlerClal URBAN INTERFACE AREA C3Yes C1No FLOOD ZONE 11Yes C3 NO DESCRIPTION OF WORK —)F TOTAL VALUATION: ,r-�� RECEIEI;<BLr i By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on the property owner's behalf. I have read this application and the information I have provid i correct. I have read the Description of Work and verify it is accurate. I a e to co Iv_ with all applicable local ordinances and state laws relating to buildi c struction. I aut rirepresentatives of Cupertino to enter the above fir{i pro rty or inspection purposes. Signature of Applicant/Agent: Date: SUPPLE NTAL INFORMATION REQUIRED rsO MEFMisctlpp 2011.doc revised 03/16/11