08120112 CITY OF CUPERTINO
BUILDING DIVIS 'N PERMIT ,CONTRAGTQRI (1�Ir�.TION h
BUILDING ADDRESS: F PERMIT NO.
21791 -1 ELECTRIC
OWNER'S NAME: PERMIT ISSUE DATE
ONE.— SAN CONTROL NO.
ARCHITECTG1NEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
UPGRD ELECTRCL SVC 60AMP
up0 LICENSED CONTRACTOR'S DECLARATION 100 AMP
im I hereby affirm wt 1 am licensed under provisions of Cltap or 9(mmmcncing Job Description
<� ¢with Scetion 70,10)of Divion.3ofdrc Business orb P efensiuns Code,and my licensee
a. in full fatand off
i n= License assn —sJ Lk.It tI'
'g, Dam 1T _,71=321, Comranar �
n p IJ' IT DECLARATION
9 W U 1 underaund my Plans shall be used u public retards
v
�LLON Licensed ProfeWan.I
3 OWNER-BUILDER DECLARATION
f 1 bereby affirm than 1 am exempt from the Com actors License law for the
p O following rounn.(Section 1031.5.Buai eas and Profecslons Code:Any city or only
�i which requires•Permit to construct,ober.improve.dcmol W,or mpmr any sw.to.
I< prior As its Wonnoc.atm mqui,en Ncapplicant for such .it,.file.signed.W,c.m
that he is Remand pursuant to the Provisions of the Comrecmrs lucve Law(Chapter 9 Sq.Ft. Floor Area Valuation
yI� (commencing with Section 70(M)of Division 3 of the Business and Professions Code)or
y — that he is exempt therefrom and the basin for the alleged exemption.Any violation of
Section 7031.5 by airy applicant for a permit subjects the applicant m•civil penalty Of APN Number Occupancy
nut mom than five hundred dollen ant($SM. P Y Type
1,u owner of the property,or my employee with wages a Neo sole compensation.
will do the work and the smac ure Isnot intended or offered for sale(See.T(44,Business
and Professin.code:The COnuactors Limine Law doer not apply to in owner of Required Inspections
property who builds or i m proves thereon,and who does such work himself or through his
awn emplo,con,provided that such improvements arc not intended oroffered for sale.If.
however.Ne building or improvement Is sold within one year of molplcuon,me owner-
builder will have Ik burden of praying that M did not build or improve for Purpose of
ink.).
❑1,as Owner of the pmpenY•am exclusively conumong with Ikensed Man anion to
convect the project(See.7014,Business aed Profession Code:)The Contractor's Li.
conte Law does not apply As an miner of property who Wilds Or improves thereon,and
who contracts for such pmlects with a contractors)licensed pursuant to the Conmacmh
License Law.
❑1 me exempt under See .B&P C for this mann
Owner Date
WORKERS COMPENSATION DECLARATION
I bcmby affirm under penalty Of perjury one of the following deelaretions:
ve and will maintain a Certificate ofConum An self-insure for Workers Compen-
on.an provided for by Samoan 3700 of the labor Code.for the performan¢of the
A,ork for which this permit is iaum.
1 have and will maimein Workers Compensation Insurance,As required by Section
Of to tabor Code,for the performance Of the wort for which Nu Permit u issued.
My Workers Compewtion Immnce,carrier and Policy number are:
Carrier.Vol -LPnAad �C at Policy NO.: V—�UIb��I PSl
FltERfI GTE O Ut�PLUN FROM WORKERS'
COMPENSATION INSURANCE
rTh'usmthon red net he completed if the permit ts(moot hundred dollars($I00)
or loss)
1 certify that in the pc lormarce of the woh for which this Permit u issued.I shall not
employ any parson in my manmrso as an become subject to the Wohmi Compensation
Laws of California.Data
Applicant
NOTICE TO APPLICANT:IL after making this Cenificao:of Exemption,you should
become subject in the Worker's Compensation provisions of de labra Code,you most
.J O forthwith comply with such provisions or Ne permit shall be doomed revoked.
Z "' CONSTRUCTION LENDING AGENCY
t—i� Ihemby.ffirm that do.uamosmuctinn mnding.,ne,for the performance of
C'r
the work for which this permit 4 issued(Sec.3091.Civ.C.)
Q Lenders Name
D z Landers Addrea
U C) I certify that 1 have read Us application and mm that the show information is
ty H conch.1 agree to comply with all city and county ordinances and sum laws relaung to
0building convection.And hereby authorim apmsenwiws of this city to enter upon the
,r C a1Wve-mmUned property for Inspection purposes.
I%)agree to saw,indemnify and keep harmless the City of Cupertino against
LH.p3 liabilities,judgments,costs and expenses which may in any way accrue against mid City
C)z in APPLICANT
Of the grantingUNDERSTANDS
of the permit. �—
tti APPLICANT UNDERSTANDS ANO WILL COMPLY WITH ALL NON-POINT Issued by: Date
E REGUI.A
t'zsa n -r+r Re-roofs
Signature of ApplicaurVContrmtor Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will Use applicant or rut=building acomams me or handle harem ous material
as defined by the Cupertino Municipal Code.Chapter 9,13,and the He his and Safety
Code.Section zss3z(an
pYes _No All roofs shall be inspected prior to any roofing material being Installed.
Will de applicant or future building occupant useequipment or devices which
If a roof is installed without first obtaining an inspection,I agree to remove
it baardout air conuminsm a do d by one Bay AMA Air Quality Managoment all new materials for inspection.
mitt?
❑Ye Nu
I haw mad the WA dousmamriau mquinemenu undcrChmu rb.95 of he Califor-
nuHealth&SafcIy COM.Sections 25505,25533amt 25534.1 understand Unifde building
does trot currently haw a unant,sun itis my mrponsmuity An entify the oeeupant of the
irtments wnknm met prior m issuartm of a crosuesm of Occo . Signature of Applicant Date
o
1-2--Cl
—
Owner or auNOmed Co., Dam All roof coverings to be bass'/W*or better
CITY OF CUPERTINO
4 ITEMS OF 9 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec : Twp: Rng: Sub: Blk: Lot :
APN . . . . . . . . . 35718029 . 00
DATE ISSUED. . . . . . . : 12/17/2008
RECEIPT # . . . . . . . . . : BS000006839
REFERENCE ID # . . . : 08120112
SITE ADDRESS . . . . . : 21791 OLIVE AVE
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . .
OWNER . . . . . . . . . . . . : ROGER SY
ADDRESS . . . . . . . . . . : 21793 OLIVE AVE
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
RECEIVED FROM . . . . : A-1 ELECTRIC
CONTRACTOR . . . . . . . : ROBERT LAMANTA LIC # 27061
COMPANY . . . . . . . . . . : A-1 ELECTRIC
ADDRESS . . . . . . . . . . : 421 E HEDDING ST
CITY/STATE/ZIP . . . : SAN JOSE, CA 95112
TELEPHONE . . . . . . . . : (408) 975-9171
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ----------
1BSEISMICR VALUATION 1, 500 . 00 0 . 50 0 . 00 0 . 50 0 . 00
1EPERMITFE FLAT RATE 1 . 00 40 . 79 0 . 00 40 . 79 0 . 00
1ERT<200 UNITS 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 122 . 87 0 . 00 122 . 87 0 . 00
•
Community Development
10300 Torre Avenue
Cupertino CA 95014
H Telephone(408)777-3228
CITY OF Fax(408)777-3333
�UPEI�TINO
Building De artment
JOB ADDRESS: PERMIT #
OWNER'S NAME: R-0 S PHONE # WSb -7 Ot SS i—I
GENERAL CONTRACTOR: —( �( �� FAX #
I am not using any subcontractors-
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
s � CITY OF CUPERTINO
• OF
CUPEfiaTINO GENERAL BUILDING
PERMIT APPLICATION FORM
APN #,5Date:
'57/ �O 9, v J
Building Address:
Cj OIiV — c't tj
Mailing Address (if different from building address):
Owner's Name: Phone#:
Contractor: Phone:
I" 415� � � �
L Fax:
Contractor License #: (4.3 O L 4--i
Cupertino Business License#: 1-7O bl
Contact: Phone: t{ Ct rl5c I
• �"J Fax:
Residential Commercial
Job Description: Q
"�1� �Q�-4�- � � r�S'�-�+.LPL SEP�.I ILE �O �cw�p — to� R rv•V�
Building Permit Info:
Bldg ❑ Elect Plumb ❑ Mech ❑
Type of Construction (Usage Class): Occupancy Type:
1-A, 1-B ❑ 11/III/V-A ❑ IUIII B, IV-HT, V-B 9--�3
Valuation: Square Footage:
I SCO.
Project Size: Expressz ExpressStandard ❑ 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.builditllreen.org
Revised 10/20/08
CITY OF CUPERTINO
CITY F
CUPERTINO GENERAL BUILDING
PERMIT APPLICATION FORM
Quantity/Sf Fee ID Fee Description Fee Permit Type
Group 1GENRES or
1GENCOM
1 BBOILERI For the installation or relocation of ea M
boiler/compressor to & including 3
horsepower, or ea absorption sys to &
incl 100,000 Btu/h (29.3kw)
I BBOILER2 Installation/relocation of ea M
boiler/compressor over 3 horsepower
to & incl 15 horsepower, or ea
absorption sys over 100,000 Btu/h
1 BBOILER3 Installation/relocation of ea M
boiler/compressor over 15 horsepower
to & incl 30 horsepower, or ea
absorption sys over 500,000 Btu/h to
& incl 1,000,000 Btu/h
1 BBOILER4 Installation/relocation of ea M •
boiler/compressor over 30 hosepower
to & incl 50 horsepower, or for ea
absorption sys over 1,000,000 Btu/h to
& incl 1,750,000 Btu/h
1 BBOILER5 Installation/relocation of ea boiler or M
refrigeration compressor over 50
horsepower, or ea absorption sys over
1,750,000 Btu/h
1 BAPPLOTH For ea appliance or piece of equip M
regulated by this Code but not classed
in other appliance categories, or for
which no other fee is listed in this
code.
1 ELECINSP Other Electrical Inspections (per hour) E
1MECHINSP Other Mechanical Inspections (per M
hour)
1PLMBINSP Other Plumbing& Gas Inspections P
(per hour
IMEETING IHR Application Meeting B •