06050215BUILDING DIVISION ' PERMIT
DEVELOPMENT CORPt"06050215
OWNER'S NAME:
I
PERMITISSUMDATB
KELLY GORDEN DEVELOPMENT
12241 SARATOGA -
NE:
SANITARY NO. CONTROL NO.
(408)873-8774
ARCHTIECTYEN'GINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
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j LICENSED CONTRACTOR'S DECLARATION
�y
Job Op.a
1 heeby gflmm Nal 1 am I''=m uakr provWom of CMpWr 9 (commemin{
with Sada7000)of DivWom3oftha Ba.and Profr us Cade. ad my licensee
mraliraaandaff-w�t�e1
TEMPORARY POWER
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Da¢ Gon
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uan t ' O r UGS
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DELL
As DECLARATION51,
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1 understand my plans shall k used u Public mcorhk
shall use
BUIL
Licensed Professional
3 OatNEm BUILDER DECLARATION
�
F I am. 1 am. from the ContractorsLicense:C Law for de
Bund
mrso 7fDL3. Budnmx and Profevioli Code: Any cm or county
i fallowing moan. Sec on
which rtqulraapatronuneonman alta. Wprasa,dpermit,measig aounum
permit
25
fprsuch petor'W0eneeLaw(ukmenl
ed
previsio
^y priorW itsissuance,pursuant Connector's lneme Law
Sq. FI. Floor Area
Valuation
Wire
of (Chapter
that he is licensed punuamWthe prevision of the
(commencing with Section 7000) of Division 3 of the Budnets and Proromions Core) or
.. that k is exempt thertf em and the basis fa Use alleged eameaption Any violation of
Occupancy Type
Section 7031.3 by my applicant for a permit subjecs, the appll mat a a Civil pawky of
trot mart than five Inmate! dolan (5300).
❑ 1, as Owner of the property, or my employe with wage as their Bole ampestudon,
Required Inspections
es
will do the work.M the almame is am intended.afremd faaak(Sec. 7044, Bu.
I Jet, LAw does t apply W an owner Of
Code: The Ommuc rse
and Pmreadom W
q P
property who Wilda as Improves thamon, and wrist dueamch work hiauelratbrougb bis
Own employee. provided t:usuch improvements smnun itando aroBeradforalelf.
however, the building or improvement is sold within o. yeas ofcomplcam. dee owoer-
builder MB have the Wrda of proving that k did not Wild .Improve for purpose of
..
I. as amor of IW property. am eacludvely conoacdng with licensed conoacton to
stmt the project (Sec. 7044, Baines and professions, Code) The Conuaemh U-
te Law dose not apply man owner of prepeny who Wilds or Improves demon, and
who contracts for such projects with a conuactor(s) learned pureuent W the Coneacmh
Liam" Law.
❑ 1 am exempt under See
B k P C f. this rtaaon
Owner Dare
WORKERS COMPOIA71011 DECLARATION
I hereby aRotu Oscar parlay c(pe*" one offt following declaratimsc
I loveand will mdnuin a Curti ftam ofCaaent Wf
ss, -Insone for W.ka
rs Comp-
utian, u provided Far by Section 3700 of the Lab. Cade, for the par(. r:a of the
wart for which this permit Is issued.
0 1 have and win mdnuin W~3 CompemWon Insurance, as required by Section
3700 of dee Labor Code, for the pedamunce of the work f.whiclt this permit is iuved.
My Workers ememan Imo me anisand Policy number am:
Carrier:_ �J¢v�VltiK_� _Policy No.: 2-r7—/� 7-2U(CE'L
(This section mod tet W completed if at permit h for om hundred dollars f$ 10a)
or Ica.)
1 cmuly that In the perfm m m n of the work for which this permit is issued, I shall net
employ any person in any meaner W as W become subject W the Worked Compensation
Laws of Califomim. Dam
E TO APPLICANT. It, after making this CeNfica a of Exemption. you should
subleun W the Warkers Compensation provisions of W LaWr Code, you mus,
0 amply wide each moWiom o thin summit man W deconcd mated.
CONSTRUCTION LENDING AGENCY
1 hereby affirm the dem is a co mucdnn lending agency I'or the Perform aa of
it far which do$ permit k banned (SIL. 3097, Cl, C.)
k Address
1 certify that I have mad this application and auk that the stem information is
I all W comply with all city and county ordinsmes and auk laws relatin5 k
g construction, and hereby aulbome representatives of this city to cmcr upon the
nendoned property for impaction purposes.
(We) agree to save, indemnify and lamp harmless dee City of Cupertino against
a, Judgments, coats and expo which may in any way acerm, all said City
egueea of the {rr}ynhtinyt�f It
CANT LINDERBTAbfDS ILL COMPLY WITH ALL NON -PAINT
Will the ap#kcmt. fuuuAilding caupataoe or baulk nonstudents materW
as defined by the Cumethm Municipal Code. Chapter 9.13. and the Hasa anal Safety
Code, Section 253324)7 /
Wil the applicant Of future Wilding Occupant use equipment or devices which
vardnas air cens,mimns, u by the Bay Asa Air Quality Management
L7
❑Yea Nu
Issued by:
Re -roofs
Type of Roof
Date f Z4
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 inspection.
Signature of Applicant Date
. All roof coverings to be Class 'B" or better
E
C �1
IC
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone (408) 777-3228
Fax (408) 777-3333
Building Department
JOB ADDRESS: 2Z k}3q aaw wto^ c,Aw
PERMIT #
6 s a S'
OWNER'S NAME: V-e,
PHONE #cb-F,7 -6j 77
GENERAL CONTRACTOR:
FAX # 4c:r,-- 8-75 —fit
LWA
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following information
Owner/ Contractor Signature
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/ Contractor Signature
Date
!m 1 of 1
CITY OF CUPERTINO
IsD1:70YM1.4Xm)Doft%
Sec: Twp: Rng: Sub: Blk: Lot:
APN ........: 34258011.00
DATE ISSUED.......: 05/24/2006
RECEIPT #.........: 34543
REFERENCE ID # ...: 06050215
SITE ADDRESS .....: 22189 HAMMOND WY
SUBDIVISION .......
CITY .............: CUPERTINO
IMPACT AREA .......
OWNER ............: KELLY GORDEN DEVELOPMENT
ADDRESS ..........:
CITY/STATE/ZIP ...: ,
RECEIVED FROM
CONTRACTOR ...
COMPANY ......
ADDRESS ......
CITY/STATE/ZIP
TELEPHONE ....
OPERATOR: amyw
COPY # : 2
KELLY GORDON DEVEL.
BRIAN KELLY SR. LIC # 22726
KELLY GORDON DEVELOPMENT CORP
12241 SARATOGA - SUNNYVALE RD
SARATOGA, CA 95070
(408)873-8774
�EE ID UNIT QUANTITY AMOUNT PD -TO -DT THIS REC NEW BAL
------------------------------------------------------ --------------------
BTEMP FLAT RATE 1.00 - 62.10 0.00 62.10 0.00
EPERMITFEE FLAT RATE 1.00 38.37 0.00 38.37 0.00
TOTAL PERMIT : 100.47 0.00 100.47 0.00
METHOD OF PAYMENT AMOUNT NUMBER
----------------- ------------ ------------------
CHECK 100.47 1032
TOTAL RECEIPT 100.47
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
-------------------------------------------- ----------------------------
103 UFER 304 ROUGH ELECTRICAL
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ICCL s
WUCITY OF
PEkT1NO
CITY OF CIUPERTINO EillG�021�
TEWi P POWER
PERMIT APPLICATION FORM
APN # 341_ ^�� �
Temporary Power
Date:
5 Ly b(o .
Building Address: 22 \ 8 C�
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Owner's Name: / . `1 C
4 fi\
BUSLIC
Phone #:
yuV-9313 -8 7q.
Contractor: Phone:
License #:
Contact: Phone:.
Cupertino Business License#:
Building Permit Info:
Elect L�
Job Description: .
t�ckv
Residential Commercial ❑
Cost of Project: ZlJ�
•
Qty. if
Applicable. Fee ID
Fee Description
Fee Group
BTEMP
Temporary Power
ELECTRICAL
EPERMITFEE
Elect. Permit Issuance
ELECTRICAL
BUSLIC
Business License
BUILDING
n
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