06120109 (2).2
2�
s�
BUILDING DIVISION PERMIT
STEPHEN
ARCHITECrfENGINEER:
1 hmcby grim ths 1 am licensed under
with Section 70(X)) of Division 3 of the Busirsess t
in full furtdul of t.
License Lie. af —
I understood my plans shall W used as public retards
nnumnr mm�n
1302 LINCO
(408)265-0236"
200AMP PANEL UPGRADE
Licensed professional
OWNER -BUILDER DECLARATION
1 WMby affirm Out 1 am mxempt from the Contractor's License Law far the
following reason. (Section 7101.3. Business and Prefccsiuns Code: Any city or county
which requires a permit on co swct. eller, improve, demolish, or repair any swclum
prior to its issuance, also requires the applicant for such permit to Bk a signed .mtemc u
that W is licensed pursuant to the, provisions of the Controcon s License law (Chapter 9 5
(commencing with Section 70(10) of Division 3 of the Business and Professions Cade) or
Nat W It easmpt thomfream aced the basis for the alleged exemption. My violation of
Section 7031.3 by any applicant for a permit aubjecs to applicant to a Civil penalty of
not more than BK hundred dollars (x500). 35708004
0 L as owne of tie property, or my employees with wages as their sole emspnution,
will do tae work, and the swctme is not intended or offered for in le(Sec. 7041. Busin...
and Professions Code The, ConuxmYs License Law does but apply to an owns of
property who builds or improves dacumn, and whodoesauch work himself or through his
owe coulA yoca, provided Nat such imprommens arc not humnded araffcred for We. IL
however, the Wilding or improvement u sold within one year of completion, the owner -
builder will Isom the burden of proving Nat k did nor Wild or improv for purpose of
We.).
❑ 1. n owner of the property, am exclusively conuaning with licensed mntacrors w
com moons de project (Sec. 7044, Business and Professions Code:) 7h Contaestr's U.
cense law does not apply to in owner of property who Wilds or improves Lemon. and.
who contras for such Projects with a conuxmr(s) licensed pursuant b the Comm cases
License Law.
❑ Iamesempsunder Sec .Bh PCfar Nis...
Owner Das
WORKER'S COMPENSATION DECLARATION
I hereby affirm under peruby of perjury ono of to following declarations:
I bave and will maimaln a Ccutifiate of Consent in self -insure for WortcYs Comport.
sation, as provided for by Section 3700 of ted Labor Code, for the performance of the
work for which this permit is issued.
I have and will maintain Workers Compensation Insurance, as required by Scedon
3700 of rhe L mor Code, for Ne performance of Ne work for which this Pedro is issued.
COMPENSATION INSURANCE
sets section need Trot W completed if IW permit Is fmome hundred dollen (SI00)
less.)
certify Net in be performance of the work for which this Permit is issued. I shall nos
mploy any person in any mannerso as w become subject to the Workeri Campensadon
awe of California. Dam
NOTICE TO APPLICANT: If, after making Ns Cor iGcate of Eacmption. you should
become subject to the Worker's Compenwuon previsions of the LaWr Cade you mus
forthwith comply with such provisions or this permit shall W deemed mucked.
CONSTRUCTION LENDING AGENCY
1 hereby affirm that Ncre is a crossructinn lending agency Ibr the perournmeo of
Ne .,it for whim this permit is issued (Sce. 3097, Civ. C.)
Under's Nam.
Under's Address
1 unify Nat I have mad this application and sate, Nm the aWvc information is
Comct. 1 agree to comply with all city and county ordinances and shote laws relating to
Wilding construction, and hereby autheris mp cscnmives of Nis city as crier upon Ne,
shove-mentiuned property for inspection purposes.
(We,) agree to acre, indemnify and keep harmless Nc City of C.Pmsino against
Limilities,judgiromm. costs and expenses which may in any way areme against said City
inconsequenc.ruf.'Ncg tintof Nispermit.
BOVRCE ECaD D TENS./SAND,a'ptLL CEMPLY WI�ON-Ppltfj
HAZARDOUS MATERIALS DISCLOSURE
Will dee applicant or future Wilding acupantstom or handle hazardous material
as defined by Ne, Cupertino Municipal Codc. Chapter 9. 12. and the Hcalth and Safcty
Cake Section 35332(.)?
❑ res
Will the applicant or "ohe Wilding omvpans use equipment or devices which
emit havaNnm air eomaminans cfincd by NC Bay Arta Air Quality M .... cmcm
District?
Dyes u
I hate read haraNass mamrias requirtmcns under Chapter 6.95 of the Califon
in Hwlth&Safer ak,Scetions 35505, 23377 and 33S34.1unJcrshond NmifNc lwilJing
dare not cuocn W.earenanWm s my reanovmunv to nmifv tis'. fn��%,,.f,w
Issued by:
Re -roofs
Type of Roof
CONTROL NO.
WoKingRl Yal
Job Description
Required
$1700
Date //2 Z C -ei �—
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
Cl n of
4§UPEI�TIN0
fj
Community Development
10300 Torte Avenue
Cupertino CA 95014
Telephone (408) 777-3228
Fax(408)777-3333
Building Department
JOB ADDRESS:
106400 .�G2niC. 2 (-Qc al�d
PERMIT #
0&12-0 /0
OWNER'S NAME: 4,w,
PHONE #
GENERAL CONTRACT R:
FAX #
I am not using any subcontract / 0
ignature Date
Please check applicable subcon ctors and complete the followine 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
CITY OF CUPERTINO
• 2 ITEMS OF 2 PERMIT RECEIPT OPERATOR: amyw
COPY # : I
•
•
Sec: Twp: Rng: Sub: Blk: Lot:
APN ........: 35708004.00
DATE ISSUED.......: 12/20/2006
RECEIPT #.........: BS000000042
REFERENCE ID # ...: 06120109
SITE ADDRESS .....: 10400 SCENIC BLVD
SUBDIVISION .......
CITY .............: CUPERTINO
IMPACT AREA .......
OWNER ............: STEPHEN WONG
ADDRESS ..........i
1.
CITY/STATE/ZIP ...: CUPERTINO CA,
95014-2720
RECEIVED FROM ....:
RECEIPT INTERFACE
CONTRACTOR .......:
BRIAN JOHNSTON LIC # 23411
COMPANY ..........:
JOHNSTON ELECTRICAL CONTRACTOR
ADDRESS ..........:
1302 LINCOLN AVE, STE 204
CITY/STATE/ZIP
...: SAN JOSE, CA 95125
TELEPHONE ........:
(408)266-0236
FEE ID UNIT QUANTITY
------------------
AMOUNT PD -TO -DT THIS
REC
NEW BAL
---------
BELEC200 METERS
---- ---------- ----------
1.00 29.43 0.00
29.43
----------
0.00
EPERMITFEE FLAT RATE
1.00 38.37 0.00
38.37
0.00
TOTAL PERMIT
---------- ---------- -------7--
67.80 0.00
67.80
----------
0.00
METHOD OF PAYMENT
-----------------
CHECK
TOTAL RECEIPT :
AMOUNT
----------67.80
---------------
67.80
VOICE ID DESCRIPTION
-------- ------------------------ ---
304 ROUGH ELECTRICAL
505 FINAL ELECTRICAL
REFERENCE NUMBER
--------------------
750
VOICE ID DESCRIPTION
-------- ----------------------------
FINAL ELECTRICAL ENERGY
... U'3/3U/�2U06"14: 36-TiV .dU6 llY"IM3 1................CITY CliFrAf INO........_............................................ w6bu U1.............
E
CITY OF CUPERTINO I ��
cm PERMIT APPLICATION FORM
APN#�'l-- 6s -GUT
Fee Dncripdm
Date:. `2L Z 0(p
�
BO`1�O
Other Apphances
(Kdifferentfrombl MTu addms):
�J�7
Owner's Name:
Boiler <- 12%000 Btu
Phorre # O
Cenuucwr: e7 -1,f G l
Boiler> 100K to 500K Btu
Li¢mse#: G <76,
Phone:
OO Ga 3ucenseN.
_ 1
Building Pemtit info:
Bldg ❑ Blcc1t
Plumb ❑
MachJob ❑
Residential o Q 1i e l
O�
-al ❑
SgYt. Floor Area:
Cousbucaon Tax
SqFt:
Cost of Pmjeet: \� �:
Ind/OW
Occatpmtey G
Type of Consbuetion:
'C7r)
Con Tax forBQ Zone
Please cba* this box tf the project k a
addWmn: 0
Proeet Sive: Standard ❑ Large ❑
Major ❑
BLMDIVG
Fee ID
Fee Dncripdm
Fee Gnsup
BAPPLOTHER
Other Apphances
14FA MANICAL
BBOILERI
Boiler <- 12%000 Btu
MECHANICAL
BBOILER2
Boiler> 100K to 500K Btu
MECHANICAL
BBOILER3
Boiler > 500K to IM Bta
MECHANICAL
BBOMER4
Bot7er> IM to 1.75 M Btu
MECHANICAL
BBOILER5
Boiler> 1.75M Btu
MECHANICAL
BCONSTAX
Cousbucaon Tax
BUIIAIVG
BCONSTAX
Ind/OW
BUMDIVG
BOONSTAXBQ
Con Tax forBQ Zone
BUILDING
BCONSTAXH
Hotel and Motel
BLMDIVG
BCONSTAXR
Constax-Resi/Mobile
BUIEDIVG
BELEC1000
Elee 600V � 1000A
ELECTRICAL
BELEClool
Else 600V > 1000A
ELECTRICAL
BELEC200
Eke Svcs 600V �-= 200A
ELECTRICAL
BENERGY
EMWBUILDIVG
BENERGYADD
Add Multi
BUIIAIVG
BINVESTIGA
Investi fie
BUILDING
/ /-L L/oma . '( "4>X!,
9 1 of3
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