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15120172CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 18641 CYNTHIA AVE CONTRACTOR: DWK CONSTRUCTION PERMIT NO: 15120172 OWNER'S NAME: LU SHA & DONG MING 18665 LOREE AVE DATE ISSUED: 12/18/2015 OWNER'S PHONE: 4086443995 CUPERTINO, CA 95014 PHONE NO: (408) 996-1186 LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL COMMERCIAL ❑ drlh INSTALL TEMPORARY POWER License Class 8 Lic. #A2� Contractor p tlK C s 2U Date % �S r tv I 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 of the work for which this permit is issued. Sq. Ft Floor Area: Valuation: $500 [performance ff a and will maintain Worker's Compensation Insurance, as provided for by ction 3700 of the Labor Code, for the performance of the work for which this APN Number: 37523003.00 Occupancy Type: permit is issued. APPLICANT CERTIFICATION I certify that I have read this application and state that the above infonnation 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 DAY � T ISSUANCE OR to building construction, and hereby authorize representatives of this city to enter 180 LED INSPECTION. upon the above mentioned property for inspection purposes. (We) 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 Iss ate: granting of this permit. Additionally, the applicant understands and will comply with all non -point source regulations per the Cupertino Municipal Code, Sect' 9.18. r Signatre ��iyz' ��/ Datp, /J �^ RE -ROOFS: All roofs shall be inspected prior to any roofing material being installed. If a roof is t installed without first obtaining an inspection, I agree to remove all new materials for inspection. ❑ OWNER -BUILDER DECLARATION Signature of Applicant: Date: I hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER I, 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) I, as owner 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 perjury one of the following three maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the declarations: Health & Safety Code, Section 25532(x) 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 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 the Health & Safety Code, Sectio s 25505, 25533, and 25534. y /(� permit is issued. Owner or authorized agent: Date-" i 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 have read 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 constriction, 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 GENERAL PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 T ORRE AVENUE • CUPERTINO, CA 850141-3255 (408) 777-3228 • FAX (=:08) 777-3333 • building cuoerino.org ❑ PLUh:BIT-G ❑ N1BCN_a:NICAL �LECTRiCA T IT / Z� "'-M15 ❑ maSCELLAI IEOUS PRorCr ADDPEss r c� �� /�1 �/� ✓2 - Z U a 3 OCvTtR NP Mli. 5�J / j ,/ I PHO?\ _ --C �� 1(�� i/ '_-' j � q� E-1✓ k.�Z STRE'cT: DDRESS CITY, STATE, ZIP C'� flO/ �� Ax CONTACT NhJE •-T-7cApAbY5 <�--`*4'% PHO��CY J �,�� k STREcT ADDRESS ,e C�C CITY, STATE, Z�3�Q /�¢ P_qX � dt� ❑ OY,.' ❑OV^ i?-3UTi�=R ❑ Ow:'7MAG--,TT CONFI?ACTOR ❑ CO\-IRACTORAGME �T ❑ .R.RC?.TCT ❑=NGP.:=R ❑ DEVELOPER ❑ i_? a�7 CONT14CTOR NPJ,i —7*k� 6401X-7LICENSE ''/- ivLP.,OER I LICENSE TiYE 1? I BUS. LIC „Gr01 f/ C0I✓IPAIN NAIL Gt%k �✓� �� / I a-NAII Ca'a?S 2`�� GJ��h G�' STREET ADDRESS g66 Z-Inree_ - I CITY, STATE, ZIP FACHITECTrri-GNEFR NAME I LICENSE I\�iJD BER BUS. LIC r CONTA_NY \IA I✓% E-1✓,Am FA- STREET ADDRESS I CITY, STATE, ZIP I PHONE USE OF ❑SFD.,DUPLEX ❑ muLTI-FAhffi.Y .PROjECT I IN' WIT DILENM ❑ Y:S PROicCTIN ❑ YrS IS MEBLDG.A.N ❑ y=S 13 U-7 DI\G: ❑ COl=G'TT_r--.CIA-T URBANI' N=E —ACE AREA ❑ I'm FLOOD ZONE ❑ 1:0 EIC=R H01V,7. ❑ NO DESCRIPTION OF WORK TOT?.LVA-LUATION: Z. By my signature below, I certify to each of the following: I am the prope,•ty owner or autborzed agent to a the L OWner,s behalf. read this applicztion and the iafornation I have provided is correct I have e read he Description of \�Tork and verify it is accurate. I agree to comply;; ith all P12 e local Grd anceS aad state la,;vs relating to b ., ding constructio,authorize re resentatives of Cupertino to enter the above-'dAnHE d •ropes for inspection purpos,. . Siyafure of A.ppl_icant/Agent: � Date: 'Z/ f S L 1;FE'� _ 1 rREQUIRED UTP P E- i - IAL LNFO-R-IAATIOI� _ z, = z =` :r O IGEUSE Obi l N;;r far. x. Y. i P. � 3'1 go— j 3x 14�iJ012� 1 SF x; 7 ff?)t1 isc,4-vp_2011. doc revised 06/21/11 iM CITY OF CUPERTINO W—FAW FRE FIS'TIMATOR — BUILDING DIVISION ADDRESS: 18641 CYNTHIA AVE FEE TDATE: 12/18/2015 REVIEWED BY: MELISSA APN: 375 23 003 1 BP#: *VALUATION: 1$500 1 *PERMIT TYPE: Electrical Permit PLAN CHECK TYPE: Alteration / Addition / Repair PRIMARY SFD or Duplex USE: 0.0 PENTAMATION 1REAP14 PERMIT TYPE: A WORK INSTALL TEMPORARY POWER SCOPE VOTE. This estimate does not include fees due to other Departments (i.e. Planning, Public Works, tire, Sanitary Seweru1strict, NCII 001 District, etc.). These.fees are based on the preliminary information available and are only an estimate. Contact theDept,for aaan'l info. FEE ITEMS (Fee Resohition 11-053 Eff. 711113 FEE QTY/FEE MISC ITEMS Afe,.,6. I'lOn ("j"ieck �Ilwnb. Pian Cheek Elec. Plan Check 0.0 hrs $0.00 Perwit.ffee., Elec. Pen -nit Fee: ]EPERMIT PNM Permit Fee: $48.00 ( .1 "Onsiruction 0iher,flittim1; ht Administrative Fee: 1ADMIN $45.00 Other Elec, Insp. 0.0 hrs $48.00 Travel Documentation Fee: jTRAvDoc $48.00 Stroniz Motion Fee: IBSEISMICR $0.50 Select an Administrative Item VOTE. This estimate does not include fees due to other Departments (i.e. Planning, Public Works, tire, Sanitary Seweru1strict, NCII 001 District, etc.). These.fees are based on the preliminary information available and are only an estimate. Contact theDept,for aaan'l info. FEE ITEMS (Fee Resohition 11-053 Eff. 711113 FEE QTY/FEE MISC ITEMS Plan Suppl. PC.Fee PME Plan Check: $0.00 Perwit.ffee., PMEE Unit Fee: $48.00 PNM Permit Fee: $48.00 ( .1 "Onsiruction Administrative Fee: 1ADMIN $45.00 Work Without Permit? 0 Yes (j) No $0.00 Travel Documentation Fee: jTRAvDoc $48.00 Stroniz Motion Fee: IBSEISMICR $0.50 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $1.00 $190.501 $0.00 T $190.501 Revised: 10/01/2015