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11100046 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10381 JUDY AVE CONTRACTOR __ __ PERMIT NO: 11100046 OWNER'S NAME: DORTHY GARDNER (� DATE ISSUED: 10/07/2011 OWNER'S PHONE: 8317600658 PHONE NO: LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG F_ PLUMB PLUMB License Class G Lic.# v / MECH RESIDENTIAL� COMMERCIAL � Contractor L �— Date 7 I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:200 AMP ELECTRICAL SERVICE UPGRADE (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 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. Sq,Ft Floor Area: Valuation:$1000 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:37508052.00 Occupancy Type: permit is issued. APPLICANT CERTIFICATION 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 PERMIT EXPIRES IF WORK IS 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 of Cupertino against liabilities,judgments, 180 DAYS FROM LAST CALLED INSPECTION. costs,and expenses which may accrue against said City in consequence of the granting of this permit. Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code,Section Issued b3rt / Date: 9.18. 1,4 J Signature Date CO RE-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,I agree to remove all new materials for t uereby affirm that I am exempt from the Contractor's License Law 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 ROOF COVERINGS TO BE CLASS"A"OR BETTER construct the project(Sec.7044,Business&Professions Code). I hereby affirm under penalty 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 the work for which this permit is issued. Safety Code,Section 25532(a)should I 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 maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the permit is issued. Health&Safety Code,Sections 25505,25533,and 25534. 1 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 o 52 orized Aent: 1491,7111Compensation laws of California. If,after making this certificate of exemption,I Date: 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.) 1 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, ARCHITECT'S DECLARATION posts,and expenses which may accrue against said City in consequence of the •ting of this permit.Additionally,the applicant understands and will comply I understand my plans shall be used as public records. _a all non-point source regulations per the Cupertino Municipal Code,Section 9.18. Licensed Professional Signature Date CITY OF CUPERTINO 6 ITEMS OF 7 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN 37508052 . 00 DATE ISSUED. . . . . . . : 10/07/2011 RECEIPT #. . . . . . . . . : BS000014975 REFERENCE ID # . . . : 11100046 SITE ADDRESS . . . . . : 10381 JUDY AVE SUBDIVISION . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . OWNER . . . . . . . . . . . . : DORTHY GARDNER ADDRESS 10381 JUDY AVE CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM . . . . : A-N-J ROTH ELECTRIC CONTRACTOR . . . . . . . : TBD - TO BE DETERMINED LIC # 00096 COMPANY TBD - TO BE DETERMINED ADDRESS . . . . . . . . . . CITY/STATE/ZIP . . . : , TELEPHONE . . . . . . . . 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, 000 .00 1. 00 0 . 00 1 . 00 0. 00 1BSEISMICR VALUATION 1, 000 . 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 174 .50 0. 00 174 .50 0 . 00 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 103 UFER 304 ROUGH ELECTRICAL 505 FINAL ELECTRICAL 00 GENERAL PERMIT APPLICATION MEP COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 10300 TORRE AVENUE •CUPERTINO, CA 95014-3255 CUPERT{NO (408)777-3228 • FAX(408)777-3333• building(E)cupertino.org MISC ❑PLUMBING ❑MECHANICAL LECTRICAL [:]MISCELLANEOUS PROJECT apDREss o J y / ,� APN OWNER NAME 'Tct 44-7e-S !�� IS" / O g3/_ & 0 MAIL STREET ADDRESS CITY, STATE,ZIP FAX CONTACT NAME PHONE E-MAII. C�Ctit•fire�f� STREETADDRESS CITY,STATE, ZIP FAX ❑ 0 ❑ OWNER-BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑CONTRACTORAGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT -7 CQkWA OLIC SE NUMB LICEN TYPE BUS.LIC#ov, EMAIL FA,.X STREET ADDRESS ° f CITY.STATE Q C7 PHONE ARCHITECTIENGINEER NAME / d LICENSE NUMBER BUS.LIC# COMPANY NAME' E-MAIL FAX 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 ,2CSC) 44 C � G �1 I e r l TOTAL VALUATION: 5 O (} TRECEIVED 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 cone j have read the Description of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating to bui ons ' . I authorize representatives of Cupertino to enter the above-identified roperty for inspection pu(poses. Signature of Applicant/Agentt' �`^� Date: l 0l '/ !/ SUPPLE AL INFORMATION REQUIRED OFFICE SE ONLY ❑ OVER-THE-COUNTER e. ❑ EXPRESS x U ❑ STANDARD U ❑ LARGE e. ❑ MAJOR MEPMiscApp_2011.doc revised 06/21111 CITY OF CUPERTINO FEE ESTIMATOR-BUILDING DIVISION ADDRESS: 10381 judy ave. DATE: 10/07/2011 REVIEWED BY: bobs. APN: BP#: -VALUATION: 1$1,000 -� PERMIT TYPE: Electrical Permit PLAN CHECK TYPE: Alteration /Addition / Repair PRIMARY FD or Duplex PENTAMATION 1 REAP2 SPERMIT TYPE: USE: WORK service upgrade. SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Services 1ERT<200 100 Amps $44 TOTALS: $44.00 Elec.Plan Check 0.0 hrs $0.00 Elec.Permit Fee: IEPERMIT Other Elec.Insp. Efl hrs $44.00 NOTE: This estimate does not include fees due to other Departments(i.e.Planning,Public Works,Fire,Sanitary Sewer District,School District,etc. . Thesefees are based on the relinina information available and are only an estimate. Contact the Dept for addn 7 info, FEE ITEMS (lee Resolution 11-053 L'f ?%1/IIZ FEE QTY/FEE MISC ITEMS PME Plan Check: $0.00 PME Unit Fee: $44.00 PME Permit Fee: $44.00 Administrative Fee: (ADMIN $41.00 Work Without Permit? C) Yes 0 No $0.00 Travel Documentation Fee: ITRA VDOC $44.00 Strong/Motion Fee: IBSEISMICR $0.50 Select an Administrative Item BldyStds Commission Fee: IBCBSC $1.001 1 SUBTOTALS: $174.501 $0.00 TOTAL FEE: $174.50 Revised: 10/01/2011 CITY OF CUPERTINO 6 ITEMS OF 7 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN . . . . . . . . : 37508052 . 00 DATE ISSUED. . . . . . . : 10/07/2011 RECEIPT #. . . . . . . . . : BS000014975 REFERENCE ID # . . . : 11100046 SITE ADDRESS . . . . . : 10381 JUDY AVE SUBDIVISION . . . . . . CITY . . . . . . . . . . . . . . CUPERTINO IMPACT AREA . . . . . . OWNER . . . . . . . . . . . . : DORTHY GARDNER ADDRESS . . . . . . . . . . : 10381 JUDY AVE CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM . . . . : A-N-J ROTH ELECTRIC CONTRACTOR . . . . . . . : TBD - TO BE DETERMINED LIC # 00096 COMPANY . . . . . . . . . . : TBD - TO BE DETERMINED ADDRESS . . . . . . . . . . CITY/STATE/ZIP . . . : , TELEPHONE . . . . . . . . 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, 000. 00 1. 00 0 . 00 1 .00 0. 00 1BSEISMICR VALUATION 1, 000. 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 174 .50 0. 00 174 .50 0 . 00 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 103 UFER 304 ROUGH ELECTRICAL 505 FINAL ELECTRICAL 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: iJd v'e- PERMIT# U(- C OWNER'S NAME: Cc.` e.S -S t e /. p n PHONE# r / L( � G77 GENERAL CONTRACTOR:A-,y.-`T k pt Clc-gr,4(- BUSINESS LICENSE # ADDRESS: Q Ts J s ✓ V e- I CITY/ZIPCODE: *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 HAVE OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE. I am not using any subcontractors: Signature Date Please check applicable subcontractors and complete the following information: SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets & Millwork Cement Finishing Electrical "�''� Q-ill e- , r/'L f 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 '-.15 Z_/ 7 //0//-;7// Owner/Contractor Signature Date CITY OF CUPERTINO BUILDING PERMR � t BUILDING ADDRESS: 10431 LANSDALE AVE CONTRACTOR: VALLEY HOME J L.DERS, PERMIT NO: 11080229 INC. OWNER'S NAME: SIELER STANLEY R.IR ET AL 1850 WARBURTON AVE STE 103 DATE ISSUED:08/31/2011 ER'S PHONE: 4084208086 SANTA CLARA,CA 95050 PHONE NO:(408)248.8000 D LICENSED CONTRACTOR'S DECLARATION — --- BUILDING PERMIT INFO: BLDG I ELECT PLUMB License Class Lic f r Contractor MECH RESIDENTIAL, COMMERCIAL ' Datc�� f � 1 hereby affirm that 1 am licensed under the provisions of Chapter 9 JOB DESCRIPTION- S[-DWI.ADDITON OF 192SQFT MASI FR BA I I I&MASTLK (commencing with Section 7000)of Division 3 of the Business& Professions BEDROOM Code and that my license is in full force and effect. 10/11/201 I-REV#I-REVISE FOOTING TO ADDI"TION-REV#I ISS'D 10/I 1/2011 1 hereby affirm under penalty of perjury one of the following two declarations: 1 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. 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 Sq.Ft Floor Area: Valuation:$42000 permit is issued. APPLICANT CERTIFICATION APN Number:3691 100700 Occupancy Type. I certify that I have read this application and state that the above information is correct. 1 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 save PERMIT EXPIRES IF WORK IS NOT STARTED indemnity 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 DgYS FRO ST CALLED INSPECTION. with all non-point source regulations per the Cupertino Municipal Code,Section I 9.18. a Issued b �� �" Signature r ° ' Date a B y' Date: � OWNER-BUILDER DECLARATION 1 hereby affirm that 1 am exempt from the Contractor's License Law for one of RE-ROOFS: the following two reasons: All roofs shall be inspected prior to any roofing material being installed If a roof is 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 riot 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 1 hereby affirm under penalty of perjury one of the following three declarations: I have and will maintain a Certificate of Consent to self-insure for Worker's HAZARDOUS MATERIALS DISCLOSURE 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. 1 will maintain I 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 ofthe work for which this Safety Code,Section 25532(x)should 1 store or handle hazardous material. permit is issued. Additionally,should 1 use equipment or devices which emit hazardous air I certify that in the performance of the work for which this permit is issued,I shall contaminants as defined bmaintain compliance y the Bay Area Air Quality Management District I will not employ any person in any manner so as to become subject to the Worker's Health&Safety Code,Sections 2.5.505,25the Cupertino 53311and 25534. icipal e,Chapter 9.12 and the Compensation laws of California. If,after making this certificate of exemption,1 become subject to the Worker's Compensation provisions of the Labor Code,I must Owne au ri da e forthwith comply with such provisions or this permit shall be deemed revoked. ate: � 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 cost end expenses which may accrue against said City in consequence of the grs of this permit.Additionally,the applicant understands and will comply wiu, mon-point source regulations per the Cupertino Municipal Code,Section ARCHITECT'S DECLARATION 9.18. 1 understand my plans shall be used as public records. Signature Date Licensed Professional