12050116 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 21750 RAINBOW DR CONTRACTOR:OWEN SIGNATURE PERMIT NO: 12050116
HOMES,INC
OWNER'S NAME: BRUCE STEAKLEY 445 S SAN ANTONIO RD STE 201 DATE ISSUED:05/142012
OWNER'S PHONE: 4086376990 LOS ALTOS,CA 94022 PHONE NO:(650)948-9420
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LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL COh1h1ERCLAh
License Class _ Licq TEMPORARY POWER POLE
Contractor 1 �k 0t1B y S I Z V)Z
1 hereby alarm that I,,li sed under the provisions of Chapler il
(commencing with Section 7000)of Division 3 of the Business&Professions
Code and that my license is in full force and effect.
1 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 whichthis permit is issued. Sq.FI Floor Area: Valuation:$100
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
APN Number:36603064.00 Occupancy 7-Ape:
permit is issued.
APPLICANT CERTIFICATION '
I cenify that 1 have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED
correct. I agree to comply with all city and county ordinances and stale laws relating WITHIN 1 SO DAYS OF PERMIT ISSUANCE OR
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save 180 DAY F M LAST CALLED INSPE TI N.
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may acerae against said City in consequence of the
granting of this permit. Additionally,the applicant understands and will comply Issued by: Date:
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18.
r q, RF,-ROOFS:
Signature Date 7 U� All roofs shall be inspected prior to any roofing material berg installed.If a roof is
installed without first obtaining an inspection.I agree to remove all new materials for
inspection.
E] ON'NF,R-RlII1,DF,R DECLARATION
I hereby affirm that 1 em exempt from the Contractor's License Law for one of Signature of Applicant: Date:
the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
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,
Business&Professions Code)
1,as owner of the property,am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE
construct the projea(Sec.7044,Business&Professions Code). 1 have read the hazardous materials requirements under Chapter 6.95 of the
California Ilealth&Safety Code,Sections 25505,25533,and 25534. twill
1 hereby affirm under penally of perjury one of the following three maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
declarations: Ilealth&Safety Code,Section 25532(a)should 1 store or handle hazardous
I have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally,should I use equipment or devices which emit hazardous
Compensation,as provided for by Section 3700 of the Labor Code,for the air contaminants as defined by the Bay Area Air Quality Management District l
performance of the work for whichthis permit is issued. will maintain compliance with the Cupertino Municipal Code.Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Ilealth&Safety Code,Sectio 25505,2 5 nJ 25534.
Section 3700 of the Labor Code,for the performance of the work for which this2
Owner or authorized agent: Date:
permit is issued-
I certify that in the performance of the work for which this permit is issued,I shall
not employ any person inany manner so as to become subject to the Worker's
Compensation laws of California. If,after making this certificate of exemption,I CONSTRUM. ON LENDING AGENCY
become subject to the Worker's Compensation provisions of the Labor Code,I must I hereby affirm that there is a construction lending agency for the performance of
forthwith comply with such provisions or this permit shall be deemed revoked. work's for which this permit is issued(Sec.3097.Civ C.)
Lender's Name
APPLICANT CERTIFICATION Lender's Address
1 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
indemnify and keep harmless the City of Cupertino against liabilities-judgments, ARCIIITECT'S DECLARATION
costs,and expenses which may acerae against said City in consequence of the I understand my plans shall be used as public records.
granting of this permit.Additionally,the applicant understands and will comply.
with all non-point source regulations per the Cupertino Municipal Code,Section Licensed Professional
9.18.
Signature Date
CITY OF CUPERTINO
FEE ESTIMATOR — BUILDING DIVISION
ADDRESS: 21750 RAINBOW DATE: 05/11/2012 REVIEWED BY: SUEW
MAPN: 3CP _ BP#: Io�U�jO// 'VALUATION: $100
''PERMIT TYPE: Electrical Permit PLAN CHECK TYPE: Alteration /Addition / Repair
PRIMARY SFD Or Duplex PENTAMATION 1REAP14
USE: PERMIT TYPE:
WORK
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Temporary Power 1ERT<200 100 Amps $44
TOTALS: $44.00
P1uwh Ph",l'herF. Flee. Plan Check 0.0 1 hrs $0.00
11r,h !•:-,nd1 Fev: Phquh. M!mit h?, Flee. Permit Fee: 1 EPERA117'
Ur;rr llrr::. l"'j, Other I'lumb My, Other Elec. Insp. 0.0 hrs $44.00
.It 10 in y, 1.% Plumb hnp. fi
NOTE: This estinmte does not include fees due to other Departments(i.e. Planning, Public Works, Fire,Sanitary Sewer District,School
District,etc. . Thesefees are based onthe reliaina information available and are only an estimate. Contact the Dept for addn 7 info.
FEE ITEMS (!ie Resohnlion 11-053 E2' 7/1/111 FEE QTY/FEE MISC ITEMS
Phw ;'hrrl, Fe(':
S71ppl.
PME Plan Check: $0.00
Suppi. h,cp Icc
PME Unit Fee: $44.00
PME Permit Fee: $44.00
i'ouc/natlun 7m.
Administrative Fee: l/DA-MN $41.00
Work Without Permit? O Yes (E) No $0.00
Travel Documentation Fee: 1TRAVDOC $44.00 A
Strone Motion Fee: IBSEISMICR $0.50 Select an Administrative Item
H_Ide Stds Commission Fee: 18CBSC $1.00
SUBTOTALS:; $174.50 $0.001 TOTAL FEE: 1 $174.50
Revised: 1/19/2012
may May. 11. 2012.; 3 : 10PM HPOweo Custom Homes No. 9C120 r. 1
IS
:■ GENERAL PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT-BUILDING DIVISION MEP
10300 TORRE AVENUE-CUPERTINO.CA 950145200
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