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08110027 CITY OF CUPERTINO Wiz; tint a;: yi 3 +'`• '? BUILDING DIVISION PERMIT £�ON I2ACTOR INk'O ,ZIVIAT,IO, s . BUILDING ADDRESS: PERMITNO. ' 5825 BOLLINGER RD _.liEQO E OWNER'S NAME: FERMITISSUEDATE j;jQ2jjRRN Q14UR�TT I— —Tl- -111 1914 1859 jASPER HIGHEnieldiffig 0 : A CONTROL NO. 1 408) 978-0562 ARCHTTEC(ENGINEER: BURRING PERMIT INFO BLDG ELECT PLUMB MECH o o LICENSED CONTRACTOR'S DECLARATION FF I hereby affirm Wel 1 and licensed under Previsimu aChePur 9(Commercial Job Description with Section 7")ofDiviuon 3 often Business and Professions Code,sod my liccnseo °oH mrullrmwm.defkca INSTL 200V RECEPTACLE FOR NEW OVEN >ja? Liceoe Clw Lk.M f O Detc COM'sedr ARCHITECT'S DECLARATION w1 uMenmmi my piw shall be used u publicrnewAs i G In Licensed Professional xy:5 OWNER.BUILDER DECLARATION a� E I bcmby affirm Nat I am exempt from Ne Con.anrYs L icons,Law for he p O following mason.(Section 711313.Busincu and Profusion Code:My city tar county e$_ which room.a permit to C.Molal,alas,hnpmw,dcmomh,w repair any suumum Prior W iu iuwne.ame requires the.,licam for such permit W fileaaigned statenee n < ha W is licensed pursuant to the provisions or the Cowlecars License law(Ompty 9 Sq.Ft.Floor Area Valuation x�C (commencing with Section 7000)of Division 3 of he final.and Rofmione Code)or y $ that W u...mpl,tEaefrorn and doe basis for We alleged aemptim Any violation of Section 7031.5 by ary appEcont for a permit subjew the applicant to a civil Pwulty,or APN Number Occupancy Type Out mice alio favi hundred dollar ISM ❑Luawrct ordk yoprny,mmY wplaym with wa,auamh sore mmpewdon, 37535016 . 00 and dothewmk and We he ContunonWunded Lawddforam(See.]014,wrom or YW PtywindN Gale:7LIC Connanon.L d IM law uch net apply 1f N Owner is Required Inspections propertywindthat daha areaouchworthimselred WrW his eObeWiprovidedthat suchim I.sold i ase trot ear C( molls..far sale If. Wilderhowever.Ne Wilding ooden of proving mid wi i in one year of c prow,fur he pwnen builder will base du Wmhn of Proring WI k did not Wild a improve rar purpose of sok.). t$1.u owner of the pmpeny.w esGudvely contracting wide licensed ennhamar3 as construct six project(Sec 7014.Boiw and Prolusions Cotler)The Can rsam's U- corse Law does not apply W an mini of Pmpeny who milds or imptowo thereon.sed. wine contracts for such prO c s with a mmsactm(s)licensed pursuant W he Contractle. LicenseLaw. ❑lameaconun Sef. .B&Pcf.mi.mason Owner �v Dam 11104 WORKERVCOMPENSATION DECLARATION I bereby aff.under Peolly m perjury one or the following decorations: I ham and will maintain•Cenfnme orcman.,m selRioure for tor. e .conpen- do,n provided for by Seedon 3700 of the labor Code,for he Performance of the work for which this Permit is issued. ❑1 dew seal will maintain Worlds Compensation huumce,as required by Section 3700 of the Lanni Code.far he pofeemance or he work farwhich this Permit is Issued My Worim'.Compewtian Is..ce anis aW Policy rummer am: Cartier. Policy No.: CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (Dissection need wtWcMrPmcd lithe Permit is(warm humbed dollar.($IOB or las) 1 cenify Wal in the performance or the work for which his pereell u Wood.1 shall am empmy any perm.in any maaq4rte�sp y a subject to he Workeri o Compcadon Laws of Calt9��a.Da 11/!J/� � APPliunt �_4'� NOnCE TO AP LICA :If.after makidithis Certificate of Exemption.you should become subject u,the Work e3 Compeesaion provisions of he labo Code you most .,O faMwihroo o ed rooke co.,Iy wide such pvointhis perink.hall he deemd. z CONSTRUCTION LENDING AGENCY I.r Ibemby Arum that more is a construction lending agency for One performance of a> the work for which this Permit W iuued(Sec.3097,Civ.C.) QLemenes Name z L.endoes Address V Q 1 cvstify that I haw rad Nis application and sued this the,show:information is Iy F' CorrteL I agree to comply with all city and county ordinances and sou laws relating W 0U building crnstrumlon.Whereby mNoriae MPnC3Cudwu of this city W enter upon he F 1 above-mentioned property fa inspection purposes (We)agree m Saw.indemnify sod kceP harmlm the City of Cupertino agaiot C4 liabilities.judgmenu.consondexpenses whichmay in anywayamac Mamslsaid City `� —� ()z in coon,race of mc'Mod.,of his permit. r-i APPLICANT UNDERSTA S AND WILL COMPLY WITH ALL NON-POINT Issued by: Date //-6 — TIONS II�mGa Re-roofs signuurt ar ApplinHAZAitDO Dau HAZARDOUS ATFALki3 DISCLOSURE Type of Roof Wiry the Cupertino Muni building occope.Cbanlaorewand die hamtl us and Saf ty - u donned by 25 Cupertino Municipal code.Chapter 9.12.and Ne Health arta Safely Code,Section sss3l(.)7 is No (]Yes All roofs shall he inspected prior to any roofing material being installed. V Will he applicant orffuture Wilding occupant Mc equipmml or devim which If a roof is installed without first obtaining an inspection,I agree to remove til haa4rdoo air cwtaminanu u defined by the Bay Area Air Quality Management all new materials for inspection. wi.7 ❑Yes LNo I have mil the haardmumarerials roquivemrnuunder Charyer6.95 mhe Califon nu HnlN&Safety Cade.S.cd.25505.25533eW 534.1uuiewanddeaifdse Wilding does non curmmlY haw a v ook Nat it is my refouse ling W notify use raupant of the regnvemc.taw mmoR metpiwWiss OraCmtiri.WarDCt17Mm- Signature of Applicant Date O All roof coverings to be Class'%W'or better Owns,o auNarvsd+gent Oa CITY OF CUPERTINO .' 3 ITEMS OF 3 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN . . . . . . . . .. 37535016 . 00 DATE ISSUED. . . . . . . : 11/06/2008 RECEIPT #. . . . . . . . . : BS000006565 REFERENCE ID # . . . : 08110027 SITE ADDRESS . . . . . : 5825 BOLLINGER RD SUBDIVISION . . . . . . . CITY . . . . . . . . . . . . . : CUPERTINO IMPACT AREA . . . . . . . OWNER . . . . . . . . . . . . .. LUTHERN CHURCH OF OUR SAVIOR ADDRESS . . . . . . . . . . : 14846 ACTON DR CITY/STATE/ZIP . . . : SAN JOSE, CA 95124 RECEIVED FROM . . . . : NEAL TRENERY CONTRACTOR . . . . . . . : TIMOTHY J. HORSTMAN LIC # 26733 COMPANY . . . . . . . . . . : HECO ELECTRIC INC ADDRESS . . . . . . . . . . : 1850 JASPER HIGHLANDS CITY/STATE/ZIP . . . : MORGAN HILL, CA 95037 TELEPHONE . . . . . . . . : (408) 978-0562 FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL lBSEISMICO VALUATION 200 . 00 0 . 63 0 . 00 0 . 63 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 82 . 21 0 . 00 82 . 21 0 . 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CREDIT CARD 82 . 21 MC --------------- TOTAL RECEIPT 82 . 21 • / o Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone(408)777-3228 CITY OF Fax(408)777-3333 16UPEkTINO Building De artment JOB ADDRESS: PERMIT # 3R-� l3cll:mss„ Soo 6 ( 7 � lI 00 1 OWNER'S NAME: L u 41, h ✓rC h 0 4 Our 1, ,10, PHONE # 410 8 2�i U' s v sC5 GENERAL CONTRACTOR: Ow�cr (311:Ufe FAX # 4id8' SSL 3T$ I am not using any subcontractors: Signature Date Please check applicable subcontractors and complete the followinginformation: SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets &Millwork Cement Finishing Electrical "eco ElPcfr:c Tic. 2 Co 7 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 11 o' Owner/C tractor Signature Date ��l1ooe7 CITY OF CUPERTINO CITY OF CUPEQ INU GENERAL BUILDING PERMIT APPLICATION FORM APN # 3q �- Date: Building Address: 58-2 S- doll:hSer ?oQi o Mailing Address (if different from building address): Owner's Name: Pho e#: L here Ckr .Sa r (qO� ) X52 - O34S Contractor: Phone:Ct�og l q79 , ©SGa ��ecp [ lectr'C the. Fax: 4f0� l9foS — 7ye Contractor License#: �2g,� aye Cupertino Business License #: '3 Contact: IJ&41 -1-rt?ne j Phone: �n 6;05- d$/5 • Fax: Residential Commercial Job Description: TnS+A // o2a2U' V recePig01e �oe ✓1eW p V e n Building Permit Info: Bldg ❑ Elect Plumb ❑ Mech ❑ Type of Construction (Usage Class): Occupancy Type: 1-A, 1-B ❑ II/IIUV-A ❑ II/III B, N-HT, V-B A - 3 Valuation: 1,®0 Square Footage: Project Size: Ex ress Standard ❑ Large ❑ Major ❑ Green Building: Please complete relevant portion of the Green Building/LEED Checklist & attach it to the application or if applicable, include in plan set& the sheet index. • Points Achieved: For help, contact Build it Green at www.buildifureen.org Revised 10/20/08