12040164CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 1440 ROSE GARDEN LN
CONTRACTOR: T
PERMIT NO: 12040164
OWNER'S NAME: WELLS ROBERT W AND DEBRA 1
a PC h C__.
DATE; ISSUED: 04/30/2012
OWNER'S PHONE: 4082524544
PHONE. NO:
❑ LICENSED CONTRACTOR'S DECLARATION
BUILDING PERMIT INFO: BLDG r ELECT r PLUMB r
License Class ��-3 Lic. q f7a� y
r r r
COMMERCIAL
r /�'
Contractor t4 l�Oh,L Q4 __IElo Diu, ` 0-17
MECH RESIDENTIAL
hereby affirm that 1 am licensed under the provisions of Chapter 9
JOB DESCRIPTION: ELECTRICAL PANEL UPGRADE TO 200AMPS
(commencing with Section 7000) of Division 3 of the Business & Professions
Code and that my license is in full force and effect.
I hereby affirm under penally 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.
Sq. FI Floor Area:
Valuation: $1800
I have and will maintain Worker's Compensation Insurance, as provided for by
Section 3700 of the Labor Code, for the performance of (he work for which this
permit is issued.
APN Number: 36617035.00
Occupancy Type:
APPLICANT CERTIFICATION
I certify (hat I have read this application and state that the above information is
corecl. 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
PERMIT EXPIRES IF WORK IS NOT STARTED
upon the above mentioned property for inspection purposes. (We) agree to save
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
costs, and expenses which may accrue against said City in consequence of the
180 DAYS FROM LAST CALLED INSPECTION.
granting of this permit. Additionally, the applicantunderstandsand will comply
with all non -point source regulations per the Cupertino Municipal Code, Section
�J/C��—/ `%-3� •/a
9.18.
Issued by: /�//v �7f� EZ,/ Date:
�/w
Dater -3
Signature
RE -ROOFS:
Cl OWNER -BUILDER DECLARATION
All roofs shall be inspected prior to any roofing material being installed. If a roof is
1 hereby affirm that I am exempt from the Contractor's License Law for one of
installed without first obtaining an inspection, I agree to remove all new materials for
the following two reasons:
inspection.
I, as owner of the property, or my employees with wages as their sole compensation,
will do the work, and the structure is not intended or offered for sale (Sec.7044,
Signature of Applicant: Dale:
Business & Professions Code)
1, as owner of the properly, am exclusively contracting with licensed contractors to
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
construct the project (Sec.7044, Business & Professions Code).
HAZARDOUS MATERIALS DISCLOSUREdeclarations:
1 hereby affirm under penalty of perjury one of the following three
I have and will maintain a Certificate of Consent to self -insure for Worker's
I have read the hazardous materials requirements under Chapter 6.95 of the
Compensation, as provided for by Section 3700 of the Labor Code, for the
California Health & Safety Code, Sections 25505, 25533, and 25534. 1 will maintain
performance of the work for which this permit is issued.
compliance with the Cupertino Municipal Code, Chapter 9.12 and the Ilealth &
I have and will maintain Worker's Compensation Insurance, as provided for by
Safety Code, Section 25532(a) should 1 store or handle hazardous material.
Additionally, should I use equipment or devices which emit hazardous air
Section 3700 of the Labor Code, for the performance of the work for which this
contaminants as defined by the Bay Area Air Quality Management District 1 will
permit is issued.
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
I certify that in the performance of the work for which this permit is issued,) shall
Health & Safety Code, Sections 25505, 25533, and 25534.
not employ any person in any manner so as to become subject to the Worker's
Compensation laws of California. If, after making this certificate of exemption, I
Ovrpjk or et ori d age t: I y
Date:
become subject to the Worker's Compensation provisions ofthe Labor Code, I must
-4
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
APPLICANT CERTIFICATION
I hereby affirm that there is a construction lending agency for the performance of work's
I certify that I have read this application and state that the above information is
for which this permit is issued (Sec. 3097, Civ C.)
correct. I agree to comply with all city and county ordinances and state laws relating
Lender's Name
to building construction, and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We) agree to save
Lender's Address
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
costs, and expenses which may accrue against said City in consequence of the
ARCHITECT'S DECLARATION
granting of this permit. Additionally, the applicant understands and will comply
with all non -point source regulations per the Cupertino Municipal Code, Section
I understand my plans shall be used as public records.
9.18.
Licensed Professional
Signature Date
CUPERTINO
GENERAL PERMIT APPLICATION M E P
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228 • FAX (408) 777-3333 • buildin°(fcuoertino.orn misc
n PLUMBING I—I MECHAMCAL M/ELECIRICAL MMI1%M1,NF(li1c
PROJECT ADDRESS 1 GC r e�
APNf
_J
OWNflINAME �� 1 J
- —�✓ ��
E -N'`¢
STREET ADDRESS / 6
CITY, STATE, ZIP
FAX
CONTACT NAME , / J
Ptl
E-MAM
,n
°fCY
I�LOWNER ❑ OWNER.BUODEA . ❑ OWNERAGENr ❑ CDNIRACTOR ❑ CONTRACTOR AUNT ❑ ARORfFLT ❑ ENGOlEER ❑ DEVELOPER ❑ TEN NT
111 �
CONTRACTOR NAME LI � I
EJCPNSE
(7 '/
"CEYIffR 1Q
Bus. LLC M
pf1
COMPANY NAM.1KEvert
— ?�7^�K�
SM=AD117 07o ScMa tAp v
/
BT1*,� v4i � ')
/jpT?
V/
ARCiDTECTFNGINFFa NAME
LICENSE NUMBER
BUS. LIC E
COMPANY NAME
E-MAIL
FAX
SnUMT ADDRESS
CTLY. STATE ZIP
PHONE
USE OF �SFD wDUP1EX ❑ MOLTI-FAMD.Y `
RURDLNG. COMMEKOAL
PROIELTM WRDf.WO ❑ YFS
URBAN WERFAQAM ❑NO
PROIECTN 11 YES
FLOOD ZONE [3 NO
IS THE BLDG AN ❑ YES
EICHLEI HOME! [3 NO
DESCRIPTION OF WORK
TOTAL VALUATION: �D /') �'
RECFNm BY:
By my sigoanae below, I certify to each of the follawkT.. I son the property owner or authorized agent to act on the propelryCowuces behalf I bave Rad this
application and the inl'otmation I have provided is correct have read the Description of Wark and verify it is accurate. I agree to comply with all applicable local
Ordinances and swe laws relating wl.190ding construction. •1 anth_orirt representatives of Cupertino to enter the a'b love-ideoti5ed property for mspectiau pulimses.
SigaetmeofAppbmnOAgene - Dare:
SUPPLEMENTAL INFORMATION REQUIRED
OFFICE use ONLY
m
OYRR-THF-COUNTER
d
Y
❑ EXPRESS
u
u
u
❑ STANDARD
❑ LARGE
c
❑ MAJOR
AEPMIrcApp 2011.doc revised 06121111