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CITY OF CUPERTINOa�-
BUILDIP:CDIVISIrgN pgltjyjlT
kCONTRACTORjINFORMATIQN:'e
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BUILDING ADDRESS:
PERMIT NO.
10355 I1TNCH AVE
JOHNSTONE MOYER, INC.
08080112
OWNER'S NAME:
PERMIT ISSUE DATE
I'.;I.,L.ISA JORDAN
1720 S AMPHLETT BLVD STE
08/15/2008
NE:
7 C O -
SANITARY NO. CONTROL NO.
(650) 570-6161
ARCHITECl/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
LICENSED CONTRACTOR'S DECLARATION
I Job Description
1 hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing
P
with SeCtion TOM) of Division 3 of the Business, and Profemer, code, and my lice,, is
TEMP POWER
I. full forte ad eBia'
LicenseClan �_ Lie. g
Date COmrectm
ARCHITECTS DECLARATION
I undcraanJ my plans shall he used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
I arehy alTi. Nat I am exam', from Ne Contractors Limn. Law for me
following moan. (Section 5031.3. Business and Pmllcomuns Cale: My city or county
which mCut a Ilerrltlt In commuct, aILLT. Iniromm. demlllom. a, .,.I, my sWRYR
! prior wits isaamc. also requires also applicant for such permit a Bk a signal summon,
he is Hatched Cmumm rs License Law(ClnPmr 9
Sq. Ft. Floor Area-
Valuation
that parsam to the provisions her the
omencing with S ]000) of Division 3 of the Bush. and Professions Co k) or
(commencing mdoa
$50 50
mat he Is exempt mraerham and the that, for the alleged eumptials Any violation of
Section 7031.5 by any applicant for a Permit subjects the aPplicun W a Civil Wally OfNumber
3 7 5 4 3 0 2
Occupancy T
Pane Y yPe
m mom man flue hundred chinas, ($5ao).
0.
Luheanof Ne proputy, with Wages thew hale compewnon,
r is amended her,Readfor
will dDthewolk. and thehe (plyo. Business
ntnot.
Required Inspections
tOutat.
had Pmrusiou Cade: The Canuutof, Livens Law does Out appy lf am awher
Ch
nd WhO is
emywhobuildsoremphases,hereon,andwho aressuchwork
or eedNmughh.
Own provided that such improvements am not intended aoRemd for ole
Own ewr.
avid
men,
i vot r,
buildingorimprovementishathwithinone you of coreFiction.theiac,
holder
all
bailder wit, love the burden her proving W, he did ns,, buLid or improve for puryase her
of
sok.).
❑ I. as owner of the mummy, am excht ively chairman, with licensed cmnaulars m
construct the project (Sec. TMC. Business and Professions Code;) The Comma usts V -
cense Law ams not appy to in owner of property who builds or improm thereon, and,
who contracts for such projects with a conwcur(s) Hemmed Formant to Ne Contractor's
Lice¢ Law.
El I am earept under See ,B&PC for Iles won
Owner Dam
WORKERS COMPENSATION DECLARATION
101 hereby a(fam under penalty of perjury ane or the following declarations
, 1 ham and will mainuin aCcnifteom of Consent to self-heure for Workers Compon-
aadom, a provided fm by Semon 3]00 of the labor Cak, fm t e perfarmamm of the
work for which this permit is hued.
❑ 1 have and will maimmin Workers Compensation Inmrnm, as mquined by Scaon
37M ofd,Uta Code, for N,puformutec ofthe work for which this permit is issued.
'
My Worylue',s��Compensationn( 1runce artier and Policy number sm:
Grrier. L'�1yW�'g0 Y1P! Polity Na.:ffs//gryyaJ Wn-s7
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
.
(Thu xgian heed not C completed ifthe permit is foram, hundred dollars ($100)
or less)
I certify met in the performance of the work for which this Permit Is Lased. 11112111 mt
employ any peraan in my mMnerve as m became Mbje„ to the WWIXra' L'Oh1PCWO Oo
Laws of California. Dam
Applicant
NOTICE TO APPLICANT: If. afer making this Certificate of Exemption, you mould
become snbjcc, to ,he Worteri eorepcnudon pmvWom of Ne Labor Code, you most
faMwith comply with such pmvisimes or this permit shall be dumnd revoked.
I
j CONSTRUCTION LENDING AGENCY
1homhy IRnn that them isaconnrmunn lending agency for the radwa umeof
the work for which Nis permit Is named (She. 3097. Civ, C.)
Landers Name
Under, Mdress
I codify thee, I have read this applicadon and sue thu de above Of.u. I,
Cama I agree w comply with all city and county on ironces and are laws relating to
building commumdon, and hemby autharim mprea ratiwa ofthis city to enter upon the
alcove-mejudgm for IIepCLLOn which
(We) agree to hew, indemnify old keep humless the City of Cupertino against
judgments. suing ex tenses which may in any way accmhe,gdnst sena City
may
incilisaperdg, of ate
in conrqumce of thhe grating of this permlL
APPLICANT UNDER AND,,$SS...AAA�D WILL COMPLY WITH ALL NON -POINT
Issued by:
SOURCE REDU
Date
Re -roofs
e SNS
amgnuum ofA pn r
AZARDOUS MATERIALS DISCLOSURE
Type Of Roof
Will de appliant m future Wilding a:cuPat mom or handle haardoa material
a d,nned by the Cupertino Municipal Code. Chapter 9.13. and de Heald, and Safety
Coto. Seam zss32(m)]
❑ Ya 11N.
All roofs shall be inspected prior to any roofing material being installed.
Will thea applicant building aces which
pp g pant use equipment her
If a roof is installed without first obtainingan inspection, I agree to remove
P g
Matas
iurhvardno air cmmumiwmu u defined by the Bay Atha Air Quality Managemcn,
all new materials for inspection.
m
El Y. 019.
I have mad de hoaNua rm mriau mquimmems under CIUPW6.95 ofdm Califor-
nia Health & Safety Calc. Scream M505,25533 soul 25534.1 momehand thus if the balding
doa mal comendy have agpiren, that it It my rcappnsibility, to notify the oaupml of the
requirements which roup* me or issuamx of a Ceru(cae of OcC panty.
Signature of Applicant Date
fol a
All roof coverings to be Class 'A" or better
Ow c'maathons ,g,n, "
• 4 :ITEMS OF 4
CITY OF CUPERTINO
PERMIT RECEIPT
Sec: Twp: Rng: Sub: Blk: Lot:
APN ........: 37543020.00
DATE ISSUED.......: 08/15/2008
RECEIPT #.........: BS000005803
REFERENCE ID # ...: 08080112
SITE ADDRESS .....: 10355 FINCH AVE
SUBDIVISION .......
CITY .............: CUPERTINO
IMPACT AREA .......
OPERATOR: patg
COPY # : 1
OWNER ............: ELLISA JORDAN
ADDRESS ..........: 10355 FINCH AVE
CITY/STATE/ZIP ...: CUPERTINO CA, 95014-3412
RECEIVED FROM ....: KEN CAMP
CONTRACTOR .......: JOHN A MOYER, PRESIDENT LIC # 30268
COMPANY ..........: JOHNSTONE MOYER, INC.
ADDRESS ..........: 1720 S AMPHLETT BLVD STE 250
CITY/STATE/ZIP ...: SAN MATEO, CA 94402
TELEPHONE ........: (650) 570-6161
• FEE ID UNIT QUANTITY AMOUNT PD -TO -DT THIS REC NEW BAL
1BSEISMICR VALUATION
50.00
0.50
0.00
0.50
0.00
.IE:PERMITFE FLAT RATE
1.00..
40.79
0.00
40.79
0.00
1.ERTG200 UNITS
1.00
.40-.79
0.00
40.79
0.00
].TRAVDOC FLAT RATE
1.00
40.79
0.00
40.79
0.00
TOTAL PERMIT
----------
122.87
----------
----------
0.00
122.87
----------
0.00
METHOD OF PAYMENT
-----------------
CREDIT CARD
TOTAL RECEIPT :
AMOUNT
---------------
122.87
---------------
122.87
VOICE ID DESCRIPTION
-------- ----------------------------
402 TEMPORARY POWER
•
REFERENCE NUMBER
--------------------
VISA
VOICE ID DESCRIPTION
-------- ----------------------------
CITY OF
• CUPEkTINO
CITY OF CUPERTINO
TEMP POWER
PERMIT APPLICATION FORM
OCW 0l/6�
APN #
2,01 U°
Fee ID
Date:
.� o
Permit Type
Building Address:
Res. Temp Power >IK
Amps
E
1REAP14
lj
1 ERT<200
Owner's Name:
E
Phone #:�8 _ 4395
Contractor: �o��
1N`
Phone #: C ST.D S'7o-<-►41
/7z6 g, dew pt,►sl�r3l,� 9.Zsv
NQk qqni6z—
1 EPERMITFE
Fax #: CISCO s'►o-41��
Contact: �^ �p
Phone #:
Contractor License #: `t3 >S%8R% r/`
� c cod, F'., Q r t pr c� 22007%
Cupertino Business License #:
� O to
Job Description:c;: �
--rein
R
Residential
Commercial ❑
Valuation (cost of project)
Travel & Documentation
Fee
B
12',
Quantity
Fee ID
Fee Description
Fee Group
Permit Type
IERT>1K
Res. Temp Power >IK
Amps
E
1REAP14
lj
1 ERT<200
Res. Temp Power <200
Amps
E
IERT2001K
Res. Temp Power 200-1K
Amps
E
/
1 EPERMITFE
Electric Permit Issuance
E
1 ELCPLNCK
Electric Plan Check
E
1BSEISMICR
Seismic Residential
B
IRAVDOC
Travel & Documentation
Fee
B
CS
«(eco:.
CITY OF
CUPEkTINO
CITY OF CUPERTINO
TEMP POWER
PERMIT APPLICATION FORM
Quantity
Fee ID
Fee Description
Fee Group
Permit Type
1BSEISMICO
Seismic Commercial
B
10EAP14
1 ECT<200
Commercial Temp Power
<200 Amps
E
IECT>lK
Commercial Temp Power
>1KAm s
E
IECT2001K
Commercial Temp. ower
100-1K Amps
E
1TRAVDOC '
Travel & Documentation
Fee
B
1BUSLIC
Business License
B
0
•
1J
CITY OF
(& PMkTINO
0
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone (408) 777-3228
Fax(408)777-3333
Building Department
JOB ADDRESS:
. 3.5-s- /=;ham
PERMIT #
6 i -L
OWNER'S NAME: EII q,d
PHONE #
GENERAL CONTRACTOR:,
FAX #
I am not using any subcontractors:
ignature Date
Please check applicable subcontractors and complete the followine information:
Owner/ ontractor Signature
811s �oR
Date
SUBCONTRACTOR
BUSINESS NAME
BUSINESS LICENSE #
Cabinets & Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring: Carpeting
Linoleum / Wood
Glass / Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting / Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/ ontractor Signature
811s �oR
Date