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12010073 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10195 WESTERN DR CONTRACTOR:SANTA CLARA VALLEY PERMIT NO: 12010073 ELECTRIC OWNER'S NAME: TILLMAN JESSE L AND MARION C 500 LAURELWOOD RD#8 DATE ISSUED:01/10/2012 OWNER'S PHONE: 4082578137 SANTA CLARA,CA 95054 PHONE NO:(408)985-8162 LICENSED CONTRACT 'S DECLARATION r– �� BUILDING PERMIT INFO: BLDG' ELEC1` PLUMB License lass Lic.# jj O t��`�1Z MECH I— RESIDENTIAL COMMERCIAL Contract.Z-AA Date L. I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:INSTALL 20AMP/120 VOLT FOR 2 RECEPTACLES AT (commencing with Section 7000)of Division 3 of the Business&Professions BEDROOM LOCATION,SERVICE UPGRADE Code and that my license is in full force and effect. I hereby affirm under penalty of perjury one of the following two declarations: I 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. 1 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 Sq.Ft Floor Area: Valuation:$1900 permit is issued. APPLICANT CERTIFICATION APN Number:35911005.00 Occupancy Type: 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 to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We)agree to save PERMIT EXPIRES IF WORK IS NOT STARTED indemnify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City in consequence of the WITHIN 180 DAYS OF PERMIT ISSUANCE OR granting of this permit. Additionally,the applicant understands and will comply 180 DAYS FROM LAST CALLED INSPECTION. with all non-point source regulations per.the Cupertino Municipal Code,Section 9.18. Issued b St Date ❑ OWNER-BUILDER DECLARATION RE-ROOFS: I hereby affirm that I am exempt from the Contractor's License Law for one of All roofs shall be inspected prior to any roofing material being installed.If a roof is the following two reasons: installed without first obtaining an inspection,I agree to remove all new materials for I,as owner of the property,or my employees with wages as their sole compensation, inspection. will do the work,and the structure is not intended or offered for sale(Sec.7044, Business&Professions Code) Signature of Applicant: Date: I,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044,Business&Professions Code). ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER I hereby affirm under penalty of perjury one of the following three declarations: HAZARDOUS MATERIALS DISCLOSURE I 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 I have read the hazardous materials requirements under Chapter 6.95 of the performance of the work for which this permit is issued. California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain 1 have and will maintain Worker's Compensation Insurance,as provided for by compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health& Section 3700 of the Labor Code,for the performance of the work for which this Safety Code,Section 25532(a)should I store or handle hazardous material. Additionally,should I use equipment or devices which emit hazardous air permit is issued. contaminants as defined by the Bay Area Air Quality Management District I will I certify that in the performance of the work for which this permit is issued,I shall maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the not employ any person in any manner so as to become subject to the Worker's Health&Safety Code,Sections 25505,25533,and 25534. Compensation laws of California. If,after making this certificate of exemption,I become subject to the Worker's Compensation provisions of the Labor Code,It forthwith comply with such provisions or this permit shall be deemed revoked. Date:_ APPLICANT CERTIFICATION CONSTRUCTION LENDING AGENCY I certify that I have read this application and state that the above information is I hereby affirm that there is a construction lending agency for the performance of work's correct.I agree to comply with all city and county ordinances and state laws relating for which this permit is issued(Sec.3097,Civ C.) to building construction,and hereby authorize representatives of this city to enter Lender's Name upon the above mentioned property for inspection purposes.(We)agree to save indemnify and keep harmless the City of Cupertino against liabilities,judgments, Lender's Address costs,and expenses which may accrue against said City in consequence of the granting of this permit.Additionally,the applicant understands and will comply ARCHITECT'S DECLARATION with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. 1 understand my plans shall be used as public records. Signature Date Licensed Professional CITY OF CUPERTINO 7 ITEMS OF 8 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN . . . . . . . . : 35911005. 00 DATE ISSUED. . . . . . . : 01/10/2012 RECEIPT #. . . . . . . . . : BS000015721 REFERENCE ID # . . . : 12010073 SITE ADDRESS . . . . . : 10195 WESTERN DR SUBDIVISION . . . . . . CITY . . . . . . . . . . . . . . CUPERTINO IMPACT AREA . . . . . . OWNER . . . . . . . . . . . . : TILLMAN JESSE L AND MARION C ADDRESS . . . . . . . . . . : 10195 WESTERN DR CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM . . . . : SANTA CLARA VALLEY CONTRACTOR . . . . . . . : SALAS, D E LIC # 6439 COMPANY . . . . . . . . . . : SANTA CLARA VALLEY ELECTRIC ADDRESS . . . . . . . . . . : 500 LAURELWOOD RD #8 CITY/STATE/ZIP . . . : SANTA CLARA, CA 95054 TELEPHONE . . . . . . . . : (408) 985-8162 FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- ---------- -ADMIN HOURS 1.00 41. 00 0. 00 41. 00 0. 00 1BCBSC VALUATION 1, 900.00 1.00 0. 00 1. 00 0. 00 1BREMRECEP NO. OUTLETS 2 .00 44 . 00 0. 00 44 . 00 0. 00 1BSEISMICR VALUATION 1, 900 .00 0 .50 0. 00 0.50 0 .00 1EPERMITFE FLAT RATE 1 .00 44 . 00 0. 00 44 .00 0.00 1ERT<200 UNITS 1 .00 44 . 00 0. 00 44 .00 0.00 1TRAVDOC FLAT RATE 1 .00 44 . 00 0. 00 44 .00 0. 00 ---------- ---------- ---------- ---------- TOTAL PERMIT 218.50 0 .00 218 .50 0. 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CREDIT CARD 337.50 VISA --------------- TOTAL RECEIPT 337.50 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 304 ROUGH ELECTRICAL 505 FINAL ELECTRICAL 512 FINAL HANDI-CAP 0 o 7 GENERAL PERMIT APPLICATION MEP COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 (408)777-3228•FAX(408)777-3333• building(a7cupertino.org MISC CUPERTINO []PLUMBING ❑MECHANICALCTRICAL ❑MISCELLANEOUSf PROJECT ADDRESS / APN# OWNER NAME t PHO 40 ZS 7.S7 STREET ADDRESS 1r C T _ FAX CONTACT NAME PHONE E-MAIL STREET ADDRESS CITY,STATE, ZIP FAX ❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGENTVkONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT &p 90-7 LICENSE TYPE BUS.LIC# CONTRA r ClEf�� FAX S SS c, - I /1� e,S r PHONE Gn , s tx(,( I V , ARCHTTEmENGINEER NAME LICENSE /� y 7 to o COMPANY NAME' E-MAIL ( FAX `Y STREET ADDRESS CITY,STATE,ZIP PHONE USE OF SFD or DUPLEX ❑ MULTI-FAMILY PROJECT IN WILDLAND ❑ YES PROJECT IN ❑YES IS THE BLDG AN ❑YES BUILDING: . ❑COMMERCIAL URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑NO EICHLER HOME? ❑NO DESCRIPTION OF WORK z4g-�2e)\) TV TOTAL VALUATION: RECEIVED BY: By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on the property owner's behalf. I have read this application and the information I have provided is correct.,havZad cripdon of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws ction"I aue tatives of Cupertino to enter the a ove-identifiFd property for inspection pu{poses. Signature ofApplican Date: ()• �]2> SUPPLEMENT RMA QUIRED OFFICE USE ONLY W ' OVER-THE-COUNTER e. ❑ EXPRESS U W ❑ STANDARD T_ U ❑ LARGE a ❑ MAJOR MHPMrscApp_2011.doc revised 06121111 CITY OF CUPERTINO FEE ESTIMATOR-BUILDING DIVISION ADDRESS: 10195 western dr. DATE: 01/10/2012 REVIEWED BV: bobs. APN: BP#: 'EVALUATION: 1$1,900 PERMIT TYPE: Electrical Permit PLAN CHECK TYPE: Alteration /Addition/ Repair PRIMARY SFD or Duplex PENTAMATION 1 REAP10 USE: PERMIT TYPE: WORK install 20am /120 volt for 2 receptacles at bedroom location service upgrade. SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Recep/Switch/Outlets 1 BREMRECEP 2 # $44 Services 1 ERT<200 200 Amps $44 TOTALS: $88.00 Elec.Plan Check 0.0 hrs $0.00 Elec.Permit Fee: 1EPERMIT Other Elea Insp. 0.0 hrs $44.00 NOTE:This estimate does not include fees due to other Departments(Le.Planning,Public Works,Fire,Sanitary Sewer District,School District,etc. . Thesefees are based on the prelinina information available and are only an estimate. Contact the De t or addn 7 info, FEE ITEMS (I ire Resolution 11-0531'ff. 7`1.%11) FEE QTY/FEE MISC ITEMS PME Plan Check: $0.00 PME Unit Fee: $88.00 PME Permit Fee: $44.00 Administrative Fee: ]ADMIN $41.00 Work Without Permit? 0 Yes 0 No $0.00 Travel Documentation Fee: ITRAVDOC $44.00 Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item BldgStds Commission Fee: IBCBSC $1.00 SUBTOTALS: $218.50 $0.00 TOTAL,FEE: $218.50 Revised: 1/01/2012 Building Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014-3255 Telephone: 408-777-3228 C U P E RT I N O Fax: 408-777-3333 CONTRACTOR / SUBCONTRACTOR LIST JOB ADDRESS: PERMIT r OWNER'S NAME: P ONE# GENERAL CONT CTOOf , > ENSE# i8 ADDRESS: 0> j . ,Wile r-> CITY/ZIPCODESi t ' Our municipal code requires all businesses working in the city to have a City of Cupertino business license. NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE GENERAL CONTRACTOR AND ALL SUBCONTRACTORS AVE OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE. 1( I am not using any subcontracto i ture Date Please check applicable subcontractors and complete the following information: V SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets & Millwork ement Finishing Electrical V-,13 !7 Excavation Fencing Flooring /Carpeting Linoleum/Wood Glass / Glazing Heating Insulation Landscaping Lathing Masonry Painting /Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile r/C actor Signature Date