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11110063
CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10120 N DE ANZA BLVD CONTRACTOR:STRAIGHT LINE PERMIT NO: 11110063 CONSTRUCTION OWNER'S NAME: ROMAN CATHOLIC WELFARE CORP OF SAN 1575 INDUSTRIAL AVE 4B DATE ISSUED: 11/102011 ER'S PHONE: 4082526441 S/ ;DOSE,CA 95112 PHONE NO:(408)141.9660 ❑ LICENSED CONTRACTOR'S DECLARATION �� .B DESCRIPTION: RESIDENTIAL COMMERCIAL License Class Gil Lie..# 90 L7 ( � EXTEND EXISTING BRANCH CIRCUIT TO NEW OUTLET Contmctor*&i1'T1I:;% E aqdaDate — �(" ' FOR NEW ILLUMINATED SIGN I hereby affirm that 1 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:$675 1 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 APN Number:31626097.00 Occupancy Type: permit is issued. Q �s APPLICANT CERTIFICATION ` 1 certify then I have read this application and state thin the above information is PERMIT EXPIRES IF WORK IS NOT STARTED correct.l 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 FROM LAST CALLED INSPECTION. indemnify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City in consequence of the granting of this permit. Additionally,the applicant understands and will comply Issued by - Date: / �l with all non-point s cc rulati ` ,per the Cupertino Municipal Code,Section 9.18. RE-ROOFS: Signature Date 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 10 inspection. OWNER-BUILDER DECLARATION I hereby affirm that 1 am exempt from the Contractor's License Law for one of Signature of Applicant: Date: 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,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. 1 will 1 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 1 store or handle hazardous I have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally,should 1 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 Ba Area it Quality Management District 1 performance of the work for which this permit is issued. will maintain compliance with the a Municipal Code,Chapter 9.12 and I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Section 2 533, 25534. Section 3700 of the Labor Code,for the performance of the work forwhich this Owner or authorize)agent: Date:/ D permit is issued. I certify that in the performance of One work for which this permit is issued,I shall not employ any person in my manner so as to become subject to the Worker's Compensation laws of California. If,after making this certificate of exemption,I CONSTRUCTION LEN AGENCY 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 construction,and hereby authorize representatives of this city to enter n the above mentioned property for inspection purposes.(We)agree to save ARCHITECT'S DECLARATION nify and keep harmless the City of Cupertino against liabilities,judgments, and expenses which may accme 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 ftulatiors per the Cupertino Municipal Code,Section Licensed Professional 9.18. Signature Dale Building Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014-3255 U P ERT I N O Telephone: 408-777-3229 Fax: 408-777-3333 CONTRACTOR / SUBCONTRACTOR LIST JOB ADDRESS: Q (`y PERMIT# U OWNER'SNAME: Fel PHONE# 62^ 52 'bo Dy GENERAL CONTRACTOR: j;+1-A- l . ecdrrz BUSINESS LICENSE# ADDRESS: k P# . 50ylope CAMWA /ZIPCODE: '3&Idxot ctzk as. *Our municipal code requires all businesses working in the city to have a City of Cupertino business license. NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE GENERAL CONTRACTOR AND ALL SUBCON A TORS AVE OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE. J— / o 1 am not using any subcontractors: — ( ` Signature Date Please check applicable subcontractors and complete the following information: 4/ SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE# Cabinets & Millwork Cement Finishing Electrical , l-I)),.a. Excavation Fencing Flooring/ Carpeting Linoleum/Wood Glass/ Glazing Heating Insulation Landscaping Lathing Masonry Painting/ Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet[tock Tile D � Owner/Contractor Signature Date �olQ� CITY OF CUPERTINO `\ FEE ESTIMATOR- BUILDING DIVISION • ADDRESS: 10120 n de coxa blvdDATE: 11/1012011 REVIEWED BY: bobs. APN: BP#: "VALUATION: $675 *PERMIT TYPE: Electrical Permit PLAN CHECK TYPE: Alteration /Addition / Repair PRIMARY Commercial Building PENTAMATION 10EAP7 USE: PERMIT TYPE: WORK extend exisltnq branch circuit to new outlet for new illuminated sign SCOPE APPLIANCE EQUIP TYPE FEE ID QTY UNITS BP FEES Conductors 1BREMMISC 1 # $130 TOTALS: $130.00 %,h, PGI',Check Murch.P/an Check Elec. Plan Check 0.0 hrs $0.00 hlech. Permit Pee: Numb, Permit Ree: Elec.Permit Fee: IEPERMIT • Olher 9fe"h'hap. Other Plumb I, Other Elec.Insp. 0.0 hrs $44.00 ,lle h.Inc?. Fee. P/uud:. hrdp. G'let•.Ing. Vee: NOTE: This estimate does not Includejees due to other Departments(ke.Planning,Public Works,Fire,Sanitary Sewer District,School District,eta). These fees are based on the prefinina In ormatlon available and are only an estimate. Contact the Dept for addn7 infa FEE ITEMS (Fee Resolution I1-053 Eff 7/U1Il FEE QTY/FEE MISC ITEMS Plan Check Tec. Sttp1,l. PC.Pee PME Plan Check: $0.00 Permit FCe: Supp/. lrtsp Pee PME Unit Fee: $130.00 PME Permit Fee: $44.00 Construction Tax Administrative Fee: IADAIIN $41.00 Work Without Permit? © Yes iE) No $0.00 A h•tmc W Planning Fres: Travel Documentation Fee: ITRAVDOC $44.00 • Strona Motion Fee: IESBISMICO $0.50 Select an Administrative Item Bldg Stds Commission Fee: IECESC $1.00 SUBTOTALS: $260.50 $0.00 I TOTAL FEE: $260.50 Revised: 10/01/2011 • CITY OF CUPERTINO 7 ITEMS OF 7 PERMIT RECEIPT OPERATOR: counter COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN . . . . . . . . : 31626097 .00 DATE ISSUED. . . . . . . : 11/10/2011 RECEIPT #. . . . . . . . . : BS000015296 REFERENCE ID # . . . : 11110063 SITE ADDRESS . . . . . : 10120 N DE ANZA BLVD SUBDIVISION . . . . . . . CITY . . . . . . . . . . . . . : CUPERTINO IMPACT AREA . . . . . . . OWNER . . . . . . . . . . . . : ROMAN CATHOLIC WELFARE CORP OF ADDRESS . . . . . . . . . . : 10120 N DE ANZA BLVD CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM . . . . : STRAIGHT LINE ELECT CONTRACTOR . . . . . . . : STRAIGHT LINE CONSTRUCTION LIC # 21493 COMPANY . . . . . . . . . . : STRAIGHT LINE CONSTRUCTION ADDRESS . . . . . . . . . . : 1575 INDUSTRIAL AVE #B CITY/STATE/ZIP . . . : SAN JOSE, CA 95112 TELEPHONE . . . . . . . . : (408) 441-9660 • FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- ---------- -ADMIN HOURS 1.00 41. 00 0. 00 41. 00 0.00 1BCBSC VALUATION 675. 00 1. 00 0. 00 1.00 0.00 1BREMMISC EACH 1.00 130 .00 0.00 130 .00 0. 00 1SSEISMICO VALUATION 675 .00 0.50 0.00 0 .50 0. 00 1BUSLIC FLAT RATE 1 .00 115.00 0.00 115 .00 0. 00 1EPERMITFE FLAT RATE 1 .00 44 . 00 0. 00 44 .00 0. 00 1TRAVDOC FLAT RATE 1 .00 44 .00 0. 00 44 . 00 0. 00 ---------- ---------- --------- ---------- TOTAL PERMIT 375.50 0. 00 375 .50 0. 00 METHOD OF PAYMENT .AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CREDIT CARD 375 .50 MC --------------- TOTAL RECEIPT 375 .50 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 304 ROUGH ELECTRICAL 505 FINAL ELECTRICAL • GENERAL PERMIT APPLICATION MEP COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO, CA 950143255 (408)777-3228 • FAX(408)777-3333• buildingcacuoertino.org • CUPERTINO \ M ' S C PLUNGING MECHANICAL ELECTRICAL Elmisau.Atmous PRO=ADDRESS � /` � AFN t N V lV L� Iwo rc o C � r ?• -&Yy E-MAIL STREETADDRESS S4M� CITY, STATE,L@ C FAX CONTACT NAME �i jt PHONE _ E-MAp,. l Q r, Cr k� ann s cRY,srnrB, FAx a 0r) ❑owNER ❑ OWNER-aNLDPR ❑ OWNER AGENT WYCONTRACTOR ❑CONTRACTOR AGENT ❑ ARM=CT ❑PNONEER ❑ DE OPPA ❑TENANT CTOAN �� (EG�r,` �E NUA� tl�TYPE Bus.LIC0 COMPANY NAME E-MAIL FAX Y STREET ADDRESS QTY,STATE.ZIP PHONE AACHITECLBdGiNEER NAME UCENSE NUMBER EUS.LIC p COMPANY NAMEE-MAIL FAX STREET ADDRESS CRY,STAT$ZIP PHONE OP ❑SFTI w➢OPIbX MULTI-FAMILY PROIEL7M WEDL4W ❑ YES PROMCTD1 ❑YPS 14 THE BLDO AN CI YES BDDDEl4 ❑COMMERCIAL e URBAN A'TFAPACB AREA 0NO FLOOD ZONE ❑NO EICHLER HOM ®CNO OESCRIPRON OF WORK X �V hY�i.h 9 GI Y- if C 1704 7�S LAJ 51� h , G0. )0!1 TOTAL VALUATION: l7 RECEIVED BY: 46 J By my sigaamm below,I certify to each of the fa awing: I sin the mperty owner or atthocized agent to act on the property awn Certs behalf I have Turd this application and the information I have pro de i carrec , hav dd a ascription of Work and verify it is ac I agree to comply with al]applicable local ordinances and state laws relating m buil g ctio . an [py :smtatives of Cupertino to an tha aba]{e ¢ratified�p-arty inspection put'uses. (/ y / /U gignanue afApplicanVAgent Date: SUPPLtyaNTAL INFO N REQUrn r:.n OFFICE use ONLY u .TEE-COUNTER 6 ❑ EXPRESS Y u w ❑ STANDARD u ❑ LARGE 6 ❑ MAJOR AEPMMcApp_2011.doc revised 06/11/11