08030018 (2) CITY OF CUPERTINO "�>� '"+.�.a.2"-s" �' ' ' ''
BUILDING DIVISION PERMIT CC1NT==RACTnRTN'T` RMATION M
PERMIT NO.
BUILDING Agp(iESSN TANTAU AVE CUPERTINO ELECTRIC INC 08030018
NElR'SVN.SAMVEU: PERMIT ISSUE DATE,
FORGE & CUPERTINO LLC 1132 N 7TH ST 03/06/2008
TffONE; - (406) 991-1000 SANITARY NO. CONTROL NO.
'
ARCHITECffENGINEEW BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0, LICENSED CONTRACTOR'S DECLARATION - Job Description
AA
I lo:reby of irn Nat I am limned under pmWsions orCMpmr 9(mmmencing
;zl wiNSemion70IM))mlDnoion 3ofdrBudAAeoandProfeoiomCode.aMmylkemek RE—OPEN EXPIRED PERMIT #07040047, NO INSPECTIONS
min full fore and effee .
�qz ueene Cl Lk.p ON THIS PERMIT
�� Dam - Gmremr E, r�
CHrfECCS OECLAI ON ms`
i�< 1 undcmand my plans shall W sed u Public mrorth
ieU
o� Licensed Professional
3 Oat I am aU sept from
DECLARATION
0 a 1 Mrchy.(lith on 1 em ursine won de Contractors :My c Law for IW
O a following naioa.permit
i 7 construct.
Business and Pte.demou Cade:My city or cmumy,
$�i which myuhmu a permit requiresstuarce,also Baethe after.pplic nt forsu h permit t ore pair any stmctum
that he itscensed pursuao es theapplicantfor Conn loiuorie..Loer(Cb.pur
< IhethcincingwithSection7aNcpmvivioneo Uw oftheBuiness nkcnsclaw(Chapin9 Sq.Ft. Floor Area Valuation
%FZ-F that
is
Seclfon70n0th Oivision3n(dueBed saampa And Professions CMB)or 518000
F Nat k u esempt them(rom and de bolo for the alleged eomption.My violatfen of
Sectiot7031.5 by any applicants far a permit subjects the apPliunun a civil prnaByssNumber Occupancy Type
ad,marc them
a e hundred dollars(M). 31618 0 2 7?��
❑1.u owreraf silo property.or mY wPloyeu with wage u de'vank emnpemdom,
will do thewah,and thetwdum is not lnended or oRemd forsak(See.70a4,Budneo Required Inspections
and Profusions Cade:The Contractor's License Law doer Oat apply m an hones of q P
property who buildsorimprow thereon,andwhoduneuchwarkhinuelfor Waugh bee
Own employee,provided that such improvements All,not intended moRe ed fmsale.B.
however.W Wilding or improvement is sold within one your of cmopletiom,die owrer-
builder will have IM hurden of proWng that M did out build Or Improve for puryase of sal..).
❑1,u owner of Ne properly.am exclusively mtormting with licensed conuamms m
construct W project(Sec.7014.Business and Profusions Code:)The Commutators Li-
cense law does not apply As an owner of property who Wilds or hormones thereon.and,
who contracts for such peojeeu with acomremr(s)licensed pursuant m sive Contractors
License Law.
D lam uempl mdear 3 .B&P C far thdt.
mer
Date—
WORKERS
amWORKER'S COMPENSATION DECLARATION
1 hereby aRm under penalty of perjury ane of the following declarations.
D(have and will maintain a Carufissm of Consent toelf-insureforWaftesComperA-
sarioo,u provided for by Section 3700 of the labor Code,for W perfmmutce of the
work for which this permit is issued.
D 1 have and will maintain Workers Compensation Insurance,as required by Sm aom
3700 of Ne labor Code.for the performance of Ne work for which the permit d honed.
My Workers Compensation Insurance carrier and Policy number arc: Yk
Gnier. Z._%Lq,Q � Policy No.:� aLa'
CERTIFICATE OFEXEMPTON FROM WORKERS'
COMPENSATION INSURANCE
(Thu section need Art W completed if W permit Is furan hundred deflara(5100)
or les.)
I certify,dust in the performance of lie work for which this Permit It Warm.I shall nm
employ any person in any marmerm As to become.mbject in tie Workers'Gmpewden
Laws of Calif..!..Dam
Applicant
NOTICE TO APPLICANT:IL after making this Certificate of Eaempsion,yon aheuW
b=ome subject to the Worker's Compensation provisions of the Labor Cade,yon mass
QM
fowith comply with such provisions or this permit all W deemed toward.
Z L01CONSTRUCTION LENDING AGENCY
(-r IMmby&frm that them is a cmuvuctinn lending agency for the performance of
D:> the wark for which this permit Is laved(Sec.3091.Civ.C.)
bow QLender's Nance�J Z Landers Address
U O 1 certify Out I have mad this application and sum that the above WashaWn is
Fcorrect.I agree to comply with all city and county ordinances and sum Tawe missing An
rJ U Wilding mausoleum.and Mmbyamhorimrpmscnutivuar this city m cnmrupnn the
Wabve
o -nomlropm
utm ppeny for inspection poess.
P. (We)agree to save,indemnify and keep baseless thc City of Cupertino against
fq liabilities,judghm;us. oasandapmwa which may in any wayaccneagainstoid Gq —y
C) Z in consequence of the granting of this permit.
"v APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
s0 REGULATIO
n."—a(A< era ter 3•�-O R Re-roofs �J- --
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will dm applicam or future building nccupmastOm or handle hmmdous material
u defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
de. Dyes 171 No zssuar.
❑Yea All roofs shall be inspected prior to any roofing material being installed.
Will be applicant or frutture building occupant uecquipmrnt ordcvim which If a roof is installed without first obtaining an inspection,I agree to remove
emit hwaNnua ail conuminanu As defined by use,Bay Ama Ail Quality Managemem all new materials for inspection.
Dat ics7 M
Dyes _kNu
1 have mad the haaarduus mamrolsmquimmems under Chapter6.95 offt"ifer-
niaHcalN&Sakty Cadc.Sections MM.35533 and 25534.1 undcrsuM dss if dm ddldmg
does om eumn mw a¢nam,Nat it u my resp eAfluJity to Artily W ocaimant Of the
mquimmcnuw Ipdan suaocoofaCcrtiframora-many. Signature of Applicant Date
�? 3 (0 o$ All roof coverings to be Class "II" or better
0 nor or am t Dam -
L�
v
• CITY OF CUPERTINO
5 ITEMS OF 5 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 31618027 . 00
DATE ISSUED. . . . . . . : 03/06/2008
RECEIPT # . . . . . . . . . : BS000004092
REFERENCE ID # . . . : 08030018
SITE ADDRESS . . . . . : 103'00N TANTAU AVE
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : FORGE & CUPERTINO LLC
ADDRESS . . . . . . . . . . : 101 METRO DR STE 305
CITY/STATE/ZIP . . . : SAN JOSE, CA 95110
RECEIVED FROM . . . . : CUPERTINO ELECTRIC
CONTRACTOR . . . . . . . : RAVIZZA, EUGENE A LIC # 697
COMPANY . . . . . . . . . . : CUPERTINO ELECTRIC INC
ADDRESS . . . . . . . . . . : 1132 N 7TH ST
CITY/STATE/ZIP . . . : SAN JOSE, CA 95112
TELEPHONE . . . . . . . . : (408) 991-1000
•
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ----------- ---------- ---------- ---------- ----------
IBSEISMICO VALUATION 18, 000. 00 3 .78 0. 00 3 .78 0. 00
IELCPLNCK HOURS 1. 00 122 . 38 0. 00 122 .38 0. 00
IELECINSP HOUR 1. 00 122 . 38 0. 00 122 .38 0. 00
1EPERMITFE FLAT RATE 1. 00 40.79 0. 00 40 .79 0. 00
1TRAVDOC FLAT RATE 1. 00 40.79 0. 00 40 .79 0. 00
---------- ---------- ---------- ----------
TOTAL PERMIT 330'.12 0. 00 330 .12 0. 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------- --------------- --------------------
CHECK 330. 12 #5871
---------------
TOTAL RECEIPT 330. 12
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
304 ROUGH ELECTRICAL 505 FINAL ELECTRICAL
WPernmt Fees
� P,'l ,,Edit "actlonsi_�eyltalls 'Finks Calp .pp '- ' r
)7
iPermillnformalion..,_ _._
60umber 107040047P Status
5�i�irIAFN, 11 1', i 31618026.00 li
Address 10300 N TANTAU AVE
Owner Name FORGE &CUPERTINO LLC ;� ,
Fu . �+[CoMractorun
ee ID „ 77IFF A_ .
Tot
I PERMIT FEE 1 255.961 341.58 Fee
BREMPO_WER POWER UNITS 1.00 47.96 C e
BSEISMICOM _ VALUATION _ 18000.00 3.78 ' .
EPERMITFEE FLAT RATE 1.00 38.37 �� "T ot
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Fee I fn ormat�V ion) Credit Information I After Fact — —
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r After Fact.j
188nfINmat1c11;.-, 1 -+ i«-n m u.T-'Sr "`I"^r.-r,. 2^� 4 ! x li•. x'91' i t.
� P i �- •- .__' Multiplier.
fee ID BPLANGWK�.i ��� PLAN CHECK FEE �
units ” PER FEE' J Continuous 1
i� i t�, I .. rg i i� r•�t' . l 13 ' � .. i kb 1 . iku i QuanUtyr � ti!..�, I'i_ ; 255.961
f` I
Fee Amount f 341.581
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File;Edit' Actions'! Details 'inks Fayorjtes (ielp • . , .
errm
mit Infoal on_ _ Location Information `—
C,
�m+t Number!""i 07040047=' I�{� ;' ' Address 10300 N TANTAU AVE
.� ti...ru.r .wt : : j-' U '
a
}I' iSlafus' i } � E ,. . i + i+ city/State2+p CUPERTINMt -
'Master Number. ` � Note,$, h R ! " ` APN 31618025 00
Pr
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,
Apply Date r 04/04/2007 111 Operator. • suety — —� —
p ' 1 p I_._......_•1...:_...) Owner Entity Information=_-
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Pe mit Issue Date , 04/11/20_ Operator l beth ; _ f Owner Name .FORGE&CUPERTINO LLC
1 `ICeilificale Issued�l 0 eralor ! '
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PIT.;,� 46L.11 '+,P � AAA:"!r t 1.�,�+. 5.�.�...f.s�._,:,.,,s
�UseDefault
CeitlflCalO Type'; ° .j p., .,i•„�_�ei !' ,�,'.L�� w ..�„i`" r.l +I. t I r
.+•ICAdd101 M—
ETRO DR STE 305
ertil+cate Number
4 .w__.J� J
2i
' City/Statap SAN JOSE CA 95110
�Permit� j�'�pro ee y j� Zo � Applicant Contractor �IDefinedF+elds��`
k"r i, Y"+` .,w r . , pY
i "4
77777
Permd Details ; , P _ Purpose/Special Conditions _
� (P81mIl,Type � CELECTRCA REPLACE EXISTING DISTRIBUTION BOARD 6
III I r ,l 1 j0�;,. t , n COMMERCIAL ELECTRICAL PERMIT
Usage Class'',. ' N/A (Q I.
�
NONAPPUCABLEL as IT
ppliedjValue"'I'u 18000) + c "All
ISgUARE FT 9 0I ' + t �n ,�, � IV
�. t
�Calcurlat i' alua 01
W I
37
US C`404 Type 4
I ` At NON RES NON HSKPG
1 " Permit form a' AUTOPERMPERMIT
+sh1PvateOwner +'f t , „ " i x �
p.
x. .
77777 77777
77
rmit;issued04111/2007
Enh R
ter permit statusa 1• . - '