12100123 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10912 LEAVL'SLEY PL CON fRACfOR: I-IEALY ELECTRIC PERMITNO: 12100123
OWNER'S NAME: CALI f EDWARD 1 AND KAREN L 196 SURF ST DATE ISSUED: 10/162012
OWNER'S PHONE: 4085063731 PACT FICA.CA 94044 PI IONS NO:(415)309-4266
❑ LICENSED CONTRACTOR'S DECLARA'T'ION r I_! I--
BUILDING PERMIT INFO: BLDG ELECTPLUMB
License Class Lie.9 r_ r_: r,
Nrk��1 YLr.G l?/`Date 0 / i Z DIECFI RESIDENTIAL COMMERCIAL
COnIIaCtOr
I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION: INSTALL METER RELEASE
(commencing with Section 7000)of Division 3 of the Business&Professions
Cade and that my license is in full force and effect.
hereby affirm under penally of perjury one of the following tw'o 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:$500
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
permit is issued. APNNumber:35615030.00 Occupancy Type:
APPLICANT'CF.RTIFIC AT'ION
I certify that I have read this application and state that the above information is
correct.l agree to comply with all city and county ordinances and state laws relating PERMIT EXPIRES IF WORK IS NOT STARTED
to building construction,mid hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save WITHIN Ig DA SOF PERMIT ISSUANCE OR
indemnify
osts,a dexpenses harmless the City of Cupertino against liabilities,judgments, Igo DAYS Or LAST CALLED INSPECTION.
costs,and expenses which may accrue against said City in consequence of the
granting of this permit. Additionally,the applicant understands mid will comply
with all non-point source regulaticns per the Cupertino Municipal Code,Section Issued Date:
9.18. r
Signature Date /0 l
T'
RF-ROOFS:
❑ OWNER-BUILDER DECLARATION All roofs shall be inspected prior to any roofing material being installed.If a roof is
installed without first obtaining an inspection,1 agree to remove all new materials for
herebyaffirm that I am exempt frinn the Contractor's License Lav for one of inspection.
the following two reasons:
I,as owner of the property,or my employees with wages as their sole
compensation, Signature of Applicant: Date:
will do the work,and the structure is not intended or offered for sale(Sec.7044,
Business&Professions Code)
I,as owner of the property,am exclusively contracting with licensed contractors to ALL 1300E COVERINGS'T'O BE CLASS"A"OR BETTER
construct the project(Sec.7044,Business&Professions Code),
hereby affirm under penalty of perjury one of the following three IIA%ARDOUS MATERIAIS DISCLOSURE
declarations: I have read the hazardous materials requirements under Chapter 6.95 of the
I have and will maintain a Cenificate ofConsent to self-insure for Worker's California Ilcalth&Safriv 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 Ilcalth&
performance of the work for which this permit is issued. Safety Code.Section 25532(x)should I store or handle hazardous material.
I have and wiil 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 comm umants as defined by the Bay Arca Air Quality Management district 1 will
permit is issued. maintain compliance with the Cupertino Jlunicipal Code.Chapter 9.12 and the
Ilcalth&Safety Code.Sections_5505.25533,and 25534.
1 certify that in the performance of die work for which this permit is issued.I shall
not employ troy person in any manner so as to become subject to the Worker's Ow or oath m'zed a gent: ff
Compensation laws of Cali foria. If,ater making this certificate ofexemption,I Dnter(� �� Z
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. ONSTRUCHON LENDING AGENCY
I hereby aff rn that there is a construction lending agency for the performance of work's
APPLICANT'CERT'IFICAT'ION for which this permit is issued(Sec.3097,Civ C.)
I certify that I have read this application mid 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,mid 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, ARCIII'1'FCI'S DECLARATION
costs,and expenses which may accrue against said City in consequence of the
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
CITY OF CUPERTINO
6 ITEMS OF 6 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec : Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 35615030. 00
DATE ISSUED. . . . . . . : 10/16/2012
RECEIPT 4 . . . . . . . . . : BS000018311
REFERENCE ID # . . . : 12100123
SITE ADDRESS . . . . . : 10912 LEAVESLEY PL
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : GALET EDWARD J AND KAREN L
ADDRESS . . . . . . . . . . : 10912 LEAVESLEY PL
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014-4747
RECEIVED FROM . . . . : HEALY ELECTRIC
CONTRACTOR . . . . . . . : PAUL HEALY LIC # 33250
COMPANY . . . . . . . . . . : HEALY ELECTRIC
ADDRESS . . . . . . . . . . : 196 SURF ST
CITY/STATE/ZIP . . . : PACIFICA, CA 94044
TELEPHONE . . . . . . . . : (415) 309-4266
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- --- ------ --------- ---------- ---------- ----------
-ADMIN HOURS 1 . 00 42 . 00 0 . 00 42 . 00 0 . 00
1BCBSC VALUATION 500 . 00 1. 00 0 . 00 1 . 00 0 . 00
1BSEISMICR VALUATION 500 .00 0. 50 0 . 00 0 .50 0 .00
1EPERMITFE FLAT RATE 1 .00 45. 00 0 . 00 45 .00 0. 00
1ERT<200 UNITS 1 .00 45. 00 0 . 00 45 .00 0. 00
1TRAVDOC FLAT RATE 1 .00 45. 00 0 . 00 45 .00 0. 00
TOTAL PERMIT 178. 50 0 . 00 178 .50 0.00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CREDIT CARD 178 .50 VISA
---------------
TOTAL RECEIPT 178 .50
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
------------------- -------- ----------------------------
402 TEMPORARY POWER
CITY OF CUPERTINO
FEE ESTIMATOR - BUILDING DIVISION
ADDRESS: 10912 LEAVESLEY PL DATE: 10/16/2012 REVIEWED BY: SYLVIA
APN: BP#: 'VALUATION: $500
*PERMIT TYPE: Building Permit PLAN CIIECR TYPE: Alteration/ Repair
PRIMARY SFD or Duplex PENTAMATION 1REAP14
USE: PERMIT TYPE:
WORK INSTALL METER RELEASE
SCOPE
Alech. Plan Check Phuub. Plun Check Elec. Plan Check 0.0 hrs $0.00
,Meeh. Permit Fee: Pluinh, Permit Fee: Elec. Permit Fee: IEPERAIIT
Other Afech.Insp. Other Plumb Insp, Other Elea Insp. 0.0 hrs $45.00
,Mach.Insp. Fee: Plumb. Lisp.Fes: Elect Insp. Fee:
NOTE: This estinhate noes not include jeer due to other Departments(i.e. Planning, Puhlic I forks, Fire,Sanitary Sewer District,School
District,etc.). These eev are based on the prelintinan information available and are only air esdinate. Contact the Dept for addir'I info.
FEE ITEMS (Fee Resohnion I1-053 E2 711112) FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 = amps Electrical
Supp], PC Fee: Q Reg. Q OT 0.0 hrs $0.00 $45.00 )ERT<200 I Temporary Power
PME Plan Check: $0.00
Permit Fee: $0.00
Suppl. Insp. Fee:Q Reg. Q OT 0.0 hrs $0.00
PME Unit Fee: $0.00
PME Permit Fee: $45.00
Construction Tut:
Administrative Fee: IAD,MIN $42.00 O
Work Without Permit? O Yes (j) No $0.00 E)
Advanced Planning, Fee: $0.00 Select a Non-Residential E)
Travel Documentation Fee: ITRA I DOC $45.00 Building or Structure O
i
Strong,Motion Fee: IRSEIS,MICR $0.50 Select an Administrative Item
Bldg,Stds Commission Fee: IRCRSC $1.00
SUBTOTALS: $133.501 $45.00 TOTAL FEE: F $178.50
Revised: 10/01/2012
1 -2-1 � Z�
GENERAL PERMIT APPLICATION M E r
COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION
10300 TORRE AVENUE •CUPERTINO, CA 95014-3255 w A I
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CUPERTINO (408)777-3228 • FAX(408)777-3333• buildinCOCUDertino.oro \a/�
❑PLUMBING ❑MECHANICAL ❑ELECTRICAL ❑MISCELLANEOUS
PRorzcr ADDRESS / //i-�/�� I r' 1/'f S�e ,I ArN a :. ,5 0 3O .
OWNER NAME E 1/ `/A //C t V I PHONE 90U• SO/ 7 E-MAIL
S,READDRESS oL� / y,et-vFsL`7 p CITY, STATE,ffi
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CONTACT
CONTACT NAME PHONEI /�- E-MAIL STR -TA7DRESS /QCITY.STATEZIP
FAX
❑ OWNER ❑ Ow -B=ER ❑ OF'NERA rG Jd`CON�TRACTOR 11CCNT1tA=RAGa4T ❑ ARCH== ❑ENG:h' ❑ DEveDPER ❑ TENANT
CONTRACTOR NAME / L1C�SENU�A4BERe -27661BUS.LCa
COMPANY NAME AG `�G I C E VV-MAIL
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COMPANY NAME I E-MAIL FAX
STREET ADDRESS I CITY,STATE,ZIP PHONE
USE OF 0 SFD m DW cx FI MULTLFAMILY PROIEDT N WI DLWD O Yrs I PROTECT IN ❑ Y- I IS THE BLDG AN ❑ Yss
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804G: COMMERCIAL URBAN NTERFACE AREA NO FLOOD ZONE ❑NO OCHLER HOMO ❑NO
DESCRI ON OF WORX /l/J�l �'}
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TOTAL VALUATION: �. O(/ I RECEIVED BY:
By my signam a below,I ee o e ch a following: I am the prepery owner cr authorized agent to act on th, propq 1 owner's behalf. I have read this
application and the infonnatian I have p id- is correcL I have read the Description of Work and verify it is accurztc.(,{ager zo comply with all applicable local
ordinances and sate laws relating,W bni ina�s=ction. I authorize represenativu of Cupertino to enter the above-idea''ed prop ,, ror inspection pu"Imes.
Sigaa:u.:of AppliwnOAgeac_ D,;
$ PEME.'T.AL 'FORMATION REQUFRED OFFICE USE ONLY
-THE-COUNTER
❑ EXPRESS
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Z ❑ LARGE
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❑ NIMOR
d4EPMuc4pp_201 Ldoc revised 06/21/11 -