11120075 (2) r I CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 22480 WALNUT CIR CONTRACTOR:WIRELESS ALCHEMY INC PERMIT NO: 11120075
OWNER'S NAME: BAYYAPU PAVAN ET AL PO BOX 667 DATE ISSUED: 12/13/2011
R'S PHONE: 4087773221 WINTERS,CA 95694 PHONE NO:(916)396.1470
_LICENSED CONTRACTOR'S DECLARATION r r r7
BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class Lic.q
MECH r RESIDENTIAL r COMMERCIAL r
Contractor Date
1 hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:PG&E POLE @ CORNER OF S FOOTHILL&WALNUT
(commencing with Section 7000)or Division 3 of the Business&Professions CIRCLE
Code and that my license Is in full force and effect. Qm MONTE VISTA PARK-INSTALL METER PANEL&
ASSOCIATED CONDUIT ON EXISTING PG&E POLE
I hereby affirm under penalty of perjury one of the following two declarations:
1 have and will maintain a certificate of consent to self-insure for Worker's
Compensation,as provided for by Section 3700 of the Labor Code,for the
performance of the work for which this permit is issued.
I have and will maintain Worker's Compensation Insurance,as provided for by
Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued. Sq.F1 Floor Area: Valuation:$5000
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is APN Number:35703048.POLE Occupancy Type:
correct.I agree to comply with all city and county ordinances and state laws relating
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save
indemnify and keep harmless the City of Cupertino against liabilities,judgments, PERMIT EXPIRES IF WORK IS NOT STARTED
costs,and expenses which may accrue against said City in consequence of the
granting of this permit. Additionally,the applicant understands and will comply WITHIN 180 DAYS OF PERMIT ISSUANCE OR
with all non-point source regulations per the Cupertino Municipal Code,Section 180 DAYS FROM LAST CALLED INSPECTION.
9.18.
Signature Date Issued by: Date:
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of RE-ROOFS:
the following two reasons: All roofs shall be inspected prior to any roofing material being installed.If a roof is
I,as owner of the property,or my employees with wages as their sole compensation, installed without first obtaining an inspection,I agree to remove all new materials for
will do the work,and the structure is not intended or offered for sale(Sec.7044, inspection.
Business&Professions Code)
I,as owner of the property,am exclusively contracting with licensed contractors to Signature of Applicant: Date:
construct the project(Sec.7044,Business&Professions Code).
I hereby affirm under penalty of perjury one of the following three ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
declarations:
1 have and will maintain a Certificate of Consent to self-insure for Worker's HAZARDOUS MATERIALS DISCLOSURE
Compensation,as provided for by Section 3700 of the Labor Code,for the
performance of the work for which this permit is issued. I have read the hazardous materials requirements under Chapter 6,95 of the
I have and will maintain Worker's Compensation Insurance,as provided for by California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain
Section 3700 of the Labor Code,for the performance of the work for which this compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
Safety Code,Section 25532(a)should 1 store or handle hazardous material.
permit is issued. Additionally,should I use equipment or devices which emit hazardous air
I certify that in the performance of the work for which this permit is issued,I shall contaminants as defined by the Bay Area Air Quality Management District 1 will
not employ any person in any manner so as to become subject to the Worker's maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
Compensation laws of California. If,after making this certificate of exemption,I Health&Safety Cade,Sections 25505,25533,and 25534.
become subject to the Worker's Compensation provisions of the Labor Code,1 must
forthwith comply with such provisions or this permit shall be deemed revoked. Owner or authorized agent:
Date:
APPLICANT CERTIFICATION CONSTRUCTION LENDING AGENCY
I certify that I have read this application and state that the above information is
correct.I agree to comply with all city and county ordinances and state laws relating I hereby affirm that there is a construction lending agency for the performance of work's
to building construction,and hereby authorize representatives of this city to enter for which this permit is issued(Sec.3097,Civ C.)
upon the above mentioned property for inspection purposes.(We)agree to save Lender's Name
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
Dsts,and expenses which may accrue against said City in consequence of the Lender's Address
icanting of this permit.Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18. ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Signature Date
r Licensed Professional
• CITY OF CUPERTINO
ITEM 1 OF 1 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 35703048 .POLE
DATE ISSUED. . . . . . . : 12/13/2011
RECEIPT #. . . . . . . . . : BS000015554
REFERENCE ID # . . . : 11120075
SITE ADDRESS . . . . . : 22480 WALNUT CIR
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : BAYYAPU PAVAN ET AL
ADDRESS . . . . . . . . . . : 22480 WALNUT CIR
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
RECEIVED FROM . . . . : JOSE RAMIREZ
CONTRACTOR . . . . . . . : WIRELESS ALCHEMY INC LIC # 32887
COMPANY . . . . . . . . . . : WIRELESS ALCHEMY INC
ADDRESS . . . . . . . . . . : PO BOX 667
CITY/STATE/ZIP . . . : WINTERS, CA 95694
TELEPHONE . . . . . . . . :
• FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
-ADMIN HOURS 1.00 0.00 0. 00 0.00 0.00
1BCBSC VALUATION 5, 000 .00 0. 00 0. 00 0 . 00 0.00
1BSEISMICR VALUATION 5, 000 .00 0. 00 0. 00 0 .00 0.00
1DUPJOBCAR EACH 1.00 65. 00 0. 00 65 .00 0 .00
1EPERMITFE FLAT RATE 1 .00 0. 00 0. 00 0 .00 0.00
1ERT<200 UNITS 1.00 0. 00 0.00 0 .00 0. 00
1TRAVDOC FLAT RATE 1.00 0. 00 0 .00 0.00 0. 00
---------- ---------- ---------- ----------
TOTAL PERMIT 65.00 0.00 65.00 0. 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CREDIT CARD 65.00 VISA
---------------
TOTAL RECEIPT 65.00
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
103 UFER 304 ROUGH ELECTRICAL
505 FINAL ELECTRICAL
•