13050170 CITY OF;CUPERTINO BUILDING PERMIT
BUILDING ADDRESS:;'10250 S TANTAU AVE CONTRACTOR:TR DEVELOPMENT& PERMIT NO:13050170
CONSTRUCTION INC
OWNER'S NAME:',ANDY&JULIE;KANG 6172 BOLLINGER RD STE 151 DATE ISSUED:05/22/2013
OWNER'S PHONE: 4086914778 SAN JOSE,CA 95129. PHONE NO:(408)329-2831
❑ LICENSED CONTRACTOR'S DECLARATION
JOB DESCRIPTION: RESIDENTIAL COMMERCIAL
License Class_ Lac # > INSTALL TEMP POWER
t ! �Contractor
I hereby affiri 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 forceand.effect.
I hereby affirm under penaltyof perjury one of the following two declarations:
I have acid will maintain a'certi&ate 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 3700 ofthe Labor Code,forthe performance of the work for which this APN Number:37508041.00 Occupancy Type:
permit is issued.'
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is PEi RNII X 'MES IF WORK IS NOT STARTED
correct.I agree to comply with all city and,county ordinances and state laws relating WIT 180 DAYS OF PERMIT ISSUANCE.OR
to building!coristructibn,and hereby authorize representatives of this city to enter
upon the abdv6!mentioned property forjiuspection purposes. (We)agree to save 180 DJAIIS F OM LAST CALLED INSPECTION.
indemnify and keep,harmless.the'Citylof Cupertino against liabilities,judgments,
costs,and expenses';whicb may accrue against said City in consequence of the
granting of thts.peimr4 Additionally,the;applicant understands and will comply Issued by: Date:
with alf non point source regulatlo per the Cupertino Municip ode,Section
918. i1i! 'III III I ' �
I, i,i 2 L RE-ROOFS:
Siguaturel Date All roofs shall be inspected prior to any roofing material being installed.If a roof is
It
installed without first obtaining an inspection,I agree to remove all new materials for
III I i inspection.
❑ II OWNER BUILDER DECLARATION
.I P i Signature of Applicant: Date:
I hereby affirm th tII am gaem t from'the;Contractor's License Law for one of
the following fwo'rasonsa II II, i1 ! ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER .
I,as owner of the!piopert�,or my,employees with wages as their sole compensation,
will do;the workJind the structure is!notintended`or offered for sale(Sec.7044,
Business&Professions Gode) I
1,asoii wner of the property,am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE
construct the project(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 penury 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 d wv►ll maintain a Certificate of Consent to self-insure for Worker's material. Additionally,should I use equipment or devices which emit hazardous
I. l
Compensation as Pj yided€or b�Section 3700 of the Labor Code;for the air contaminants as defined by the Bay Area Air Quality Management Drstrict I
performance of the work far,whtph ths�perrptt is issued will maintain compliance with the Cupertino Municipal Code,Chapter 912 and
I have and will maintaq��Vorker�i IIs Compensation Insurance,as provided for by the Health&Safety Code,Sections 25505,/25533,and 25534.
Sectior13700 ofthei 01 Code for the performance of the work for which this Owner or authorized ager l Date•
permrtlisissued. ti ljl
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
Compensation laws of California. after making this certificate of exemption,I CONSTRUCTION LENDING AGENCY
become,subject to the IWgrker sl Compensation provisions of the Labor Code,I must I hereby affirm that there is a construction lending agency for the performance of
forthw' 'Ith1compily,with Iisuch'provisio or this permit shall be deemed revoked. work's for which this permit is issued(Sec.3097,Civ C.)
Lender's Name
I;I illi
"; I'p•ARPLIt'104tOERTIFICATION Lender's Address
I certify that I have;reads'application and state thattheabove information is
correct.,1 agree to,cQ pl with ail city and county;ordinances and state laws relating
to building constru9t�n and,herby „thQnze representatives of this city to enter
it illUl ISI, 1 i
upon tt e,, pyo p}egUoned prope y,o,yispection'purposes.(We)agree to save
I ARCHITECT'S DECLARATION
Inde tfy and keep harle�s thel City;of Cupertino against liabilities,judgments,
costs, p�nses r� ich'may apcn{e against said City in consequence of the I understand my plans shall be used as public records.
grantmg',of thr �eima Additionally;the appii*t understands and will comply
9with 18 all rill}t Ipi1 in`t sp a regulat onsI er�he Cupertino Municipal Code,Section Licensed Professional
,iI i., VIII
Silanatiirp� - I��Il.l�b!i,I �i� �11�11, II �L��ill�Ills1.1l I pate
I I'll, �I ISI Il l�ill !II
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GENERAL PERMIT APPLICATION MEP
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION (�1
10300 TORRE AVENUE•CUPERTINO,CA 95014-3255
CUPERTINO (408)777-3228•FAX(408)777-3333•building(&-cupertino.ora116 0 misc
❑PLUMBING ❑MECHANICAL ❑ELECTRICAL ❑MISCELLANEOUS
PROJECT ADDRESS 102;-D 5 a� LQ APN#
OWNER NAME -,K LZ PHONE 'toe-01
,.772 E-MAILSTREET ADDRESS CITY,STATE,ZIP [� FAX
CONTACT NAME PHONE E-MAIL
STREET ADDRESS CITY,STATE, ZIP FAX
❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME _ I LICENSE NUMBER LICENSE TYPE BUS.LIC#
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC#
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF ❑SFD or DUPLEX ❑ MULTI-FAMILY PROJECT IN WIIALAND ❑ YESPROJECT IN ❑YES IS THE BLDG AN ❑ YES
BUILDING: E]COMMERCIAL URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑NO EICHLER HOME? ❑NO
DESCRIPTION OF WORK
TOTAL VALUATION: 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 pr eff owner's behalf. I have read this
application and the information I have provided is correct. I have read the Description of Work and verify it is accurate. Ibkree to comply with all applicable local
ordinances and state laws relating to building construction. I authorize representatives of Cupertino to enter the above-identified property for inspection purposes.
Signature of Applicant/Agent: Date:
SUPPLEMENTAL INFORMATION REQUIRED OFFICE USE ONLY
p�W ❑ OVER-THE-COUNTER
r" ❑ EXPRESS
U
W ❑ STANDARD
z�
a ❑ LARGE
a
❑ MAJOR
MEPMiscApp_201 1.doc revised 06/21/11
CITY OF CUPERTINO
FEE ESTIMATOR-BUILDING DIVISION
"DRESS: 10250,S TANTAU AVE DATE: 05/22/2013 REVIEWED BY:
APN: BP#: 'VALUATION: $500
*PERMIT TYPE: Electrical Permit PLAN CHECK TYPE: Alteration/Addition/ Repair
PENTAMATION
PRIMARY 1 REAP 14
USE: SFD or Duplex PERMIT TYPE: i
WORK TEMP POWER
SCOPE
APPL'TANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Temporary Power 1 ERT<200 100 Amps $45
"TOTALS: $45.00
�leh.IMa �n heck Elec.Plan Check 0.0 hrs $0.00
l
k 7777
mb.Permit Fc:e: Elec.Permit Feer IEPERMIT
. Other Elec.InElec.Ins Fee:
I7'
NOTE This estimate'does not include fees due to other Departments(�a Planning,Public Works,Fire,Sanitary Sewer District,School
District'etc These ees are,based on the relimina information available and are onlyan estimate. Contact the Dept or addn 7 in a
FEE ITEMS'I(Fee Resolution 11-053 Eff. 7/1/12) FEE QTY/FEE MISC ITEMS
fj ixtz CJheekiFce.`„
zsP171.PG 1"ee
PME Plan Check $0.00
Peri nit.Fee
S"u1)P1.Jnsp lee
PME'Unit Fee;: $45.00
pME Permit F.ee: $45.00
ns 00 Tckz:
I'
Administrative Fee 'I IADMIIV $42.00
� ?Vork Without
��clvutacyecl Plcrri�P2ten�m71�'e?es:
Yes No
$0.00
VE
nttion`Fe: TRAVDOC $45.00ravel!Docum
Strong Nlotion'F'ee I, IBSEISAffCx $0.50 Select an Administrative Item
Bldg:5tdslCommissioriEee „', 1BCBSC $1.00
$178.50 $0.00 - $178:50
im
Revised: 04/29/2013
T.