12050206CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 931 NEW HAVEN CT
CONTRACTOR: MORE LAND
PERMIT NO: 12050206
CONSTRUCTION
OWNER'S NAME: TOM & SYLVIA LEY
14.54 DUSTED AVE
DATE ISSUED: 05/29/2012
OWNER'S PHONE: 4089960805
SAN.IOSE, CA 95125
PI [ONE NO: (408)221-0892
❑ LICENSED CONTRACTOR'S DECLARATION
r F
r.
BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class Lic. k y 1 l 4 l
r r r
11 II� ` 1
Contractor Ml1te Msu � r vF Date
MECH RESIDENTIAL COMMERCIAL
hereby affirm that I am licensed under the provisions of Chapter 9
JOB DESCRIPTION: INSTALLATION OF 100 AMP TEMP POWER POLE
(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 which this permit is issued.
Sq. Ft Floor Area:
Valuation: $300
1 have and will maintain Worker's Compensation Insurance, as provided for by
Section 3700 of the Labor Code, for the performance of the work for which this
APN Number: 35611046.00
Occupancy Type:
permit is issued.
APPLICANT CERTIFICATION
I certify that I have read this application and stale that the above information is
correct. I agree to comply with all city and county ordinances and state laws relating
PERMIT EXPIRES IF WORK I$ NOT STARTED
to building construction, and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We) agree to save
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
indemnify and keep harmless the City ofCupertinoagainst liabilities, judgments,
180 DAY FROM LAST CALLED INSPECTION.
costs, and expenses which may accrue against said City in consequence of the
granting of this pemtit. Additionally, the applicant understands and will comply
with all non -point source r ulal' cr the Cupertino Municipal Code, Section
, JI
Issued by: �E.Lfr✓ �i9 jLf7 Date:
9.18.
Signature Dale.. �s/alz
Rb: ROOFS:
❑ OWNER -BUILDER DECLARATION
All roofs shall be inspected prior to any roofing material beug installed. If a roof is
installed without first obtaining an inspection, I agree to remove all new materials for
1 hereby affirm that 1 am exempt from the Contractor's License Law for one of
inspection.
the following two reasons:
1, as owner of the property, or my employees with wages as their sole compensation,
Signature of Applipnt: Date:
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
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
construct the project (Sec.7044, Business & Professions Code).
I hereby affirm under penally of perjury one of the following three
HAZARDOUS MATERIALS DISCLOSURE:
declarations:
I have read the hazardous materials requirements under Chapter 6.95 of the
I have and will maintain a Certificate of Consent to self -insure for Worker's
California Health & Safety Code, Sections 25505, 25533, and 25534. 1 will maintain
Compensation, as provided for by Section 3700 of the Labor Code, for the
compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health &
performance of work for which this permit is issued.
Safely Code, Section 25532(a) should 1 store or handle hazardous material.
I have and will maintain Worker's Compensation Insurance, as provided for by
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 I will
permit is issued,
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
Health & Safety Code, Sections 25505, 25533, and 25534.
I certify that in the performance of the work for which this permit is issued, I shall
not employ any person in any manner so as to become subject to the Worker's
Owner or author''
Compensation laws of California. If, after making this certificate of exemption, I
Date:�L
become subject to the Worker's Compensation provisions of the Labor Code, I must
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of work's
APPLICANT CERTIFICATION
for which this permit is issued (Sec. 3097, Civ C)
I certify that I have read this application and state that the above information is
Lender's Name
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
Lender's Address
upon the above mentioned property for inspection purposes. (We) agree to save
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 IT ECT'S DECLARATION
granting of this permit. Additionally, the applicant understands and will comply
I understand my plans shall be used as public records.
with all non -point source regulations per the Cupertino Municipal Code, Section
9.18.
Licensed Professional
Signature Date
6 ITEMS OF 6
CITY OF CUPERTINO
PERMIT RECEIPT
Sec: Twp: Rng: Sub: Blk: Lot:
APN ........:.35611046.00
DATE ISSUED.......: 05/29/2012
RECEIPT #.........: BS000016931,
REFERENCE ID # ...:12050206
SITE ADDRESS .....: 931 NEW HAVEN CT
SUBDIVISION .......
CITY .............: CUPERTINO
IMPACT AREA .......
OPERATOR: patg
COPY # : 1
OWNER ............: TOM & SYLVIA LEY
ADDRESS .......... : 931 NEW HAVEN CT
CITY/STATE/ZIP ...: CUPERTINO CA, CA 95014-4023
RECEIVED FROM ....: MORE LAND CONSTRUCT
CONTRACTOR........: VICTOR RIVERA LIC # 28320
COMPANY ..........: MORE LAND CONSTRUCTION
ADDRESS ..........: 1454 HUSTED AVE
CITY/STATE/ZIP ...: SAN JOSE, CA 95125
TELEPHONE ........: (408)221-0892
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
300.00
1.00
0.00
1.00
0.00
1BSEISMICR
VALUATION
300.00
0.50
0.00
0.50
0.00
1EPERMITFE
FLAT RATE
1.00
44.00
0.00
44.00
0.00
-ERT<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
----------
174.50
----------
0.00
----------
174.50
----------
0.00
METHOD OF PAYMENT
-----------------
CHECK
TOTAL RECEIPT :
AMOUNT
---------------
174.50
---------------
174.50
REFERENCE NUMBER
--------------------
#2332
VOICE ID DESCRIPTION VOICE. ID DESCRIPTION
-------------------------------------------- ----------------------------
402 TEMPORARY POWER
CITY OF CUPERTINO
FEE ESTIMATOR -BUILDING DIVISION
APPLIANCE/EQUIP TYPE
ADDRESS: 931 New Haven Ct
Phunb- Plem Check
DATE: 05/29/2012
REVIEWED BY: Sean
BP FEES
APN:
BPH:
'VALUATION:
$300
*PERMIT TYPE: Electrical, Permit
Amps
PLAN CHECK TYPE: Alteration / Addition / Repair
PRIMARY SFD or Duplex
USE:
Penna l•cc,
PENTAMATION 1REAP14
PERMIT TYPE:
WORK Installation of 100 amp temp power.
SCOPE
APPLIANCE/EQUIP TYPE
FEE ID
Phunb- Plem Check
QTY
UNITS
BP FEES
Elec. Permit Fee: IEPERMIT
Temporary Power
1ERT<200
Other Elec. Insp.0.0 hrs$44.00
100
Amps
$44
Penna l•cc,
Supp/. Msp Fee
PME Unit Fee:
$44.00
PME Permit Fee:
$44.00
Con truclion far:
F-
Administrative Fee: IADMIN
$41.00
Work Without Permit? O Yes Q No
$0.00
TOTALS:
A
Travel Documentation Fee: ITRAVDOC
$44.00
Strong, Motion Fce: IBSEISMICR
NOTE: This estimate does not ineludefees due to other Departments (Le. Planning, Public Works, Fire, Sanitary Sewer District, School
District, eta). These fees are based on the preliminary information available and are only an estimate Contact the Dept for addn I info.
FEE ITEMS (Fee Resolution I1-053 Eff 7/111 U
meth. Ilam Check
Phunb- Plem Check
Elec. Plan Check 0.0 has $0.00
dlrrli. Permit Fee:
Phunh. Permit Pre:
Elec. Permit Fee: IEPERMIT
Odic Mach. ln.cp.
Other Plumb Insp.
Other Elec. Insp.0.0 hrs$44.00
.I lath. Imp, Pee:
Phmib. ht p. Fee:
lilac. Insp. Pce
NOTE: This estimate does not ineludefees due to other Departments (Le. Planning, Public Works, Fire, Sanitary Sewer District, School
District, eta). These fees are based on the preliminary information available and are only an estimate Contact the Dept for addn I info.
FEE ITEMS (Fee Resolution I1-053 Eff 7/111 U
FEE
QTY/FEE
MISC ITEMS
Plan Check hte:
Supp/. PC Fee
PME Plan Check:
$0.00
Penna l•cc,
Supp/. Msp Fee
PME Unit Fee:
$44.00
PME Permit Fee:
$44.00
Con truclion far:
Administrative Fee: IADMIN
$41.00
Work Without Permit? O Yes Q No
$0.00
Advanced Maiming Fees:
A
Travel Documentation Fee: ITRAVDOC
$44.00
Strong, Motion Fce: IBSEISMICR
$0.50
Select an Administrative Item
Oldg, Slds Commission Fee: IBCBSC
$1.00
'''I SUBTOTALS:
$174.50
$0.00
TOTAL FEE:
$174.50
Revised: 05/01/2012
GENERAL PERMIT APPLICATION M E P
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 950143255 M I
CUPERTINO rr�yyF D
❑PLUMBING .❑MECHANICAL ( ELECTRICAL [--]MISCELLANEOUS
(408) 777-3228 •FAX (408)777-3333 • buildinG(a)cuoeTtTno.or
PROIECTADDRES1 n3i hj Q� \
`T
APPIN - 11 -U L
OWNER NAME
•
1 �
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PH NE �S
E MALL
STREET ADDRESS
CCIY, STATE, ZIP
FAX
CONTACT NAME
PHO
E-MAIL
STREETADDRESS
14 4 Lill Q
-
CITY, STATE
S LL 0. 1
FAX
o'J =Z_
❑ OWNER ❑ OWNER -BUDDER ❑ OWNERAGENT
CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARc=cT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTORNAME C '� R(V. rV
LICENS ER
K9 BY kw
LICENSE TYPE
BUS. LICA
COMPANY NAME 1 i 6 r e n Qom, 1
MCI
E-MAIL w` 11
C�
FAXvxn
J�ygL
STREET ADDRESS
SSI N �`�
CITY, STA �-i C
PHO I IU
ARCHrfECT/ENGWEER NAME
LICENSE NUMBER
BUS INC R
COFIPANY NAME
E-MAIL
FAX
STREET ADDRESS
CRY, STATE, ZIP
PHONE
USE OF FD wDUPLEJ( ❑ MULTI-FAMMY
BUILDING. ❑00A RCLL
PROD NWIDLAND ❑ YES
URBAN INTERFACE AREA ON,
PROJECT IN ❑ YES
FLOOD MNE 'NO
ISTHEBLDGAN ❑ YES
EICHLER HOME? ,�NO
DESCIUFMON OF WORK (/
TOTAL VALUATION: .n /nU�
RECEIVED BY: C
By my signature below, 1 certify to each of the foil
application and the information I have provided is w
ordinances and state laws relating to building wns
Signature of Applicant/Agcnt:
g: 1 the property oumer or authorized agent to act on the property owner's behalf. I have read this
It rrad rhe Description of Work and verify it is accurate. I agree, to comply with all applicable local
ze representatives of Cupertinu to enter the abovc-idcnti pro i - r inspection purposes.
_ Date:
SUPPLEMENTAL INFORMATION REQUIRED
OFFICE USE ONLY
OVER-THE-COUNTER
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Y
❑ E\PRESS
V
m
U
❑ STANDARD
❑ LARGE
❑ MAJOR
MEPMrscApp_2011.doc revised O6/21/l1
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