05090057 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRAC'�TORiINFORMATIONf
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BUILDING ADDRESS: WILLOW GLEN ELECTRIC INC PERMIT NO95090057
1210371 MANN DR
OWNER'S NAME: PERMIT ISSUE DATE
KATHLEEN ELLIOTT 1085 WARREN AVE 09/08/2005
NE: SANITARY NO. CONTROL NO.
(408) 289-9725
AR CHITECf/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
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(�
oC we y LICENSEDCONTRACTOR'S DECLARATION COP Job Description kr'przb 11 ��q.!, ( ED
wx c I hereby.(LIC INS I am locatedONTRA under previsions of Chapter Y(commencingtld til
;x6 NSwtion700o)of Division 3ofthe Businessand Professions Codc.andmylicenseis Lai 1� I
< in mu force and.@m. UPGRADE ELECT. PANEL (200AMP) �`•`
3 M a Licen..Clazs Lk.g
-o Dnle TSDECContractor SEP /2 1005
ARCHITECTS DECLARATION
1 anderaand my plans shell W used as Public ecnNs
n e
u. Licensed Pmfcssianal It i• ±�
ap3 OWNER BUILDER DECLARATION i�;� • �e
2 1 hereby affnn that 1 am eaemp,from the Contractors License law for IM f
S p O following moron.(Section 703 IS.Business and Profesa'nns Code:Any city m county
which requires a permit to c..,t,aIle,,improve,demolish,or repair any suucerc 18 0 0
FIy Pnormi.issurnce,alw requires She applinnS for such permit to fle aligned auemcn,
f p that Misfi nadpars,ntmMPmrisi.m.rMcontr mr'w.en aw(Chapmr9 Sq.Ft. Floor Area Valuation
mF$ (commencing with Section 7000)of Division 3 of NC Business and Professions Code)or
g59— INt M s exempt therefrom and 0e basis for the alleged exemption.Any violation of
Section 7031.5 by atry,applicant fora Permit subjects the applicant to a civil penalty of
not mom Shan Rm hundred dollars(S500). Occupancy Type
E)I,as owner of Ne pmpcny an my employees with wages as their sole compensation,
will do One,work.and theswctue u not intended oroRernd far sale(S..7016•Busi.ss
and Profassinns Code:The Contractors Liecose law does not apply a an owner of Required Inspections
Property who builds orimpraves Ihettron,and whodoessuch work himselfor hhmugh his
own employers,provided thm such improvements are not inendcd oroRared(ormle If.
however.the building or improvement is sold within one year o(campleaon,the owner,
Wilder will Nva he Mrden of proving Nat W did not Wild.r improve far purpose of
sak)
❑1..away of the property em eaclmively.ntracSing with licensed camracbrs to
timam S the project(Sec.7014.Business athd Rofeasmat Cade:)Tha Contracrari Li
cones Law does not apply to an,war of property who Milds or impmms thereon,and
who contracts for such projects with a conlmcegs)licensed pursuant m the Contractor's
License Law.
E]1. esemO sG iZ_,._._„L, ' .B&P�f�O n
Owner / Y1/r/ �G Oem
WORKER'S COMPENSATION DECLARATION
1 hereby affum under parody of perjury eta of IM following declarations:
1 have and will maintain a Cenifeae of Consent to self-inxure for Workers ComPem
sari.,as provided for by Section 37M of the labor Code,for the performance of the
work for which this permit is issad.
❑1 have and will maintain Worker's Compensation Insurance.u requimd by Section
37M of Ne laborCode,for lM performance of die wank for which this permitts issued. ,
My Workers ComPe±uatian Insurance canner and Policy number ace:
Cartier. Policy No.:
CERTIFICATE OF EKEMPTON FROM WORKERS'
COMPENSATION INSURANCE
(This section need not Meomplevid if the Permit is For on hundred dollars(SIM)
less.)
1 cerufv thal in the performance of the work for which this Permit is issued.1 shall not
employ any pers.n in any man. mpsuub l;t ft Worksn'Compcnsadon
Laws of Califomi SS%% \\
AppReanl {
NOTICE TO APPLICANT.If..(let making this Ccnirmam of Essmpaim.you should
become subject in the W mkofs Compensation provisions of he Lithor Codc,you most
.JZ forthwith comply wit suchP"cions Of this(tali[shall be dccmcd mvoked.
Z O CONSTRUCTION LENDING AGENCY
7- IMrcb,.fr,.tNo here is a mmrocimm ending Menc,far be KK..rce of
C the ware fur which bus permit u issad(Sce.3097•Civ,C.)
W�A hander's Name
Z) Z Lenders Address
U 0 1 comfy that 1 have mad this application and see that Ne above informauun u
0.P COMUL 1 agree to comply with all city and county oali anew and sue laws minting to
DU building construction.and herebyauhorn,mpmsentalives of this city 10 enter upon the
rat aMvc.menuancd prep rlycosts
for
ande peN.n purposes
(We)agree to save•indemnify and loop harmless IM City of Cupertino against
.0 ret in consequence
casuend expemesmit. mey in anyway a.me ageinsl mid City
U z A APPLICANT
of the UNDERSTANDS
of this Permit.
^' APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
__AP6
50 R G_ ONS.
DS Re-roofs
hgnawrc tar pplicaHtrintractur AZARDOUS MATERIALS DISCLOSURE Dale Type of Roof
Will he applicant or future building occupant store or handle hazardous material
as
III by the Cuno Municipal Code Chapter 9.1 E,and the Health and Safety
ode, yes 25332(.)perti?
D � All roofs shall be inspected prior to any roofing material being installed.
Yes
Will the applicant or rulare building Occupant one equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
7D',.Ot7
❑Yes �l9
1 have mad the Naardous materials mquircmen s underCNpler6.95 of the Califon
Health&SafelyCodc,Sections 35505.25533 anal25534.1 understand than date Wilding
anm cwently have a tenth,0.Il is my map,mibllhymradfy tC Occupant of the
�uirtmctwbichm mctpdorlaissuan. ncemrt orOc.trnanc. $igna[ureofApplieant Dale
6� iner auth.madagcnt r� D,e All roof coverings to be Class "B"or better
- Community Development
.J 10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
�UPEkTINO
Building De artment
JOB ADDRESS: PERMIT #
0 3- l M cnez Dr OS 1) f 00s7.
OWNER'S NAME: (-aPsl LEt-(---r PHONE # rte_ a
GENERAL CONTRACTOR �( , FAX #
I am not using any subcontractors: �� LG�- a g —
Signature Date
Please check applicable subcontractors and complete the following information:
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
CITY OF CUPERTINO q "�
PERMIT APPLICATION FORM
ciry of
CUPEf�TINO
N Date: D�
Building Address: Mail*n Address if different from building address):
103-7) /�!c yr n /�r ✓� �d ><i nb Sv!
Owner's Name: Phone#:
/ fh leesl/ion 4/08 - 9 '7 3- Q Sof d
Contractor: , License#:
01,T&U Glen �le,jt- lc_ sgi9l,0- c /o
Contact: Phone: Z - q -7 Z Cupertino Business License#:
/71 Ark- ZO.-Ldre_ Fax:
Building Permit Info:
Bldg ❑ Elect Plumb ❑ Mech ❑
Job Description:
Residential Nw (,(e de �aCommercial ❑
Sq.Ft. Floor Area: q.Ft.:
Cost of Project: 0 � g� OC Occupancy Group:
Type of Construction: Please check this box if the project is a
second-story addition:
jr:oe:ctS�ize: Standard �Lar ❑ Ma'or ❑
Quantity =EDV--Di iFee GrouBAPOther A liances MECHANICAL
BBiler<= 100,000 Btu MECHANICAL
BBr> 100K to SOOKBtu MECHANICAL
BBer> 500K to 1M Btu MECHANICAL
BBr> 1M to 1.75 M Btu MECHANICAL
BBOILER5 Boiler> 1.75M Btu MECHANICAL
BCONSTAX Construction Tax BUILDING
BCONSTAX Ind/Off/Comm/ uasi BUILDING
BCONSTAXBQ Con..Tax for BQ Zone BUILDING
BCONSTAXH Hotel and Motel BUILDING
BCONSTAXR Constax—Resi/Mobile BUILDING
BELEC1000 Elec 600V <= 1000A ELECTRICAL
BELEC1001 Elec 600V > 1000A ELECTRICAL
BELEC200 Elec Svcs 600V <= 200A ELECTRICAL
BENERGY Energy BUILDING
BENERGYADD Ener Add Multi BUILDING
Ah BINVESTIGA Investigation fee BUILDING
ZS'
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X193 , c �
CITY OF CUPERTINO
°F PERMIT APPLICATION FORM
CUPEkTINO
-Quantity Fee ID Fee Description Fee Group
BMISCELL Miscellaneous Fee BUILDING
BMITIGATC Comm. Housing Mit. Fee BUILDING
BNUCOMME New Comm Electric ELECTRICAL
BNUCOMMM New Comm Mechanical MECHANICAL
BNUCOMMP New Comm Plumb PLUMBING
BOVERTWE Inspection Overtime BUILDING
TEE BPBACKFLOW Atmos beric Vacuum . PLUMBING
BPCESSPOOL Cesspool PLUMBING
BPERMFEE Bldg Permit Fees BUILDING
BPFMURE Pblg Fixture PLUMBING
BPGAS Gas Piping System Fee PLUMBING
BPINTERCEP Ind Waste Interceptor PLUMBING
BPLANCHK Plan Check Fee BUILDING
BPLANCKADD Plan Check Add Multi BUILDING
BPLANCKREP Plan Check Repeat Fee BUILDING
BPREPIPE Re i e Of Fixtures PLUMBING
BPSEWAGE Sewage Disposal PLUMBING
BPSEWER Sewers PLUMBING
BPSPRINK Lawn S rinklerBackflo PLUMBING
BPSTORM Storm/Rain Water PLUMBING
BPTRAP Kitchen Trap PLUMBING
BPVENT Alt of Drain &Vent PLUMBING
BPWATER InstaWAlter Water Pie PLUMBING
BPWHEATER Water Heater/Vent PLUMBING
BPWSVCS Main Water Service PLUMBING
BREINSPECT Reinspection Fee BUILDING
BREMACOVER A/C Unit> 10,000 cfm=ELECTRICAL
HANICAL
BREMAIRHAN A/C Units<= 10,000 cfmHANICAL
BREMAPPLI Appliance InstallHANICAL
BREMBUSWAY Remodel Busways
BREMFDCT Li tin FixturesCTRICAL
BREMFURN Relocation of FurnaceHANICAL
BREMFURNOV Relo Furnace> l OK btu MECHANICAL
BREMHEAT Heater Installation MECHANICAL
BREMINHOOD Installation of Hood MECHANICAL
BREMMISC Misc Ap aratus ELECTRICAL
BREMNRAPP Rem Non-Res A liance ELECTRICAL
BREMPOLE Pole/Platform Fixture ELECTRICAL
BREMPOWER Power Device/Apparatus ELECTRICAL
BREMRECEPT Rc tl, Switch & Outlets ELECTRICAL
BREMRELOCA Relocation of Hood MECHANICAL
BREMREPALT Re air/Alter Heating MECHANICAL
BREMRESAPP Remodel Res A liance ELECTRICAL
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CITY OF CUPERTINO
CITY OF PERMIT APPLICATION FORM , '
CUPEI,TINO
Quantity Fee ID Fee Description Fee Grou
BREMSIGNAD Rmdl Signs Add Branch ELECTRICAL
BREMSIGNS Remodel Signs, Marquee ELECTRICAL
BREMTHEATR Theatrical Lighting Fix ELECTRICAL
BREMVENFAN Vent Fan Single Duct MECHANICAL
BREVENSYS Ventilation Systems MECHANICAL
ICAL
BSCBLVD Scb Specific Plan BUILDING
BSEISMICOM Seismic Commercial BUILDING
BSEISMICRE Seismic Fee Res BUILDING
BSPECIAL Special Insection BUILDING
BSWIM Swimming Pool BUILDING
BTEMP Temporary Power ELECTRICAL
BTEMPPERM Temporary Bldg Permit BUILDING
BTEMPSVCS Temp Dist Svcs ELECTRICAL
BUSLIC Business License BUILDING
ELECTRIC Electrical sq foot ELECTRICAL
EPERMITFEE Elec Permit Issuance ELECTRICAL
MPERMFEE Mechanicals . foot MECHANICAL
MPERMITFEE Mech Permit Issuance MECHANICAL
PPERMITFEE Plumbing Permit Issue PLUMBING
PPLBG Plumbing Fee sq foot PLUMBING
PLLONGRNGC Planning LR Comme/ Multi-Fam PLANNING
PLLONGRNGR Planning Long Range Residential PLANNING
ZADDCHG Address Change BUILDING
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