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11070114 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 7819 LILAC CT CONTRACTOR:LIGHTHOUSE ELECTRIC PERMIT NO: 11070114 OWNER'S NAME: BURKLUND DALE C AND MARGARET L 236 BURNING TREE DR DATE ISSUED:07/18/2011 '�NER'S PHONE: 4082537965 SAN JOSE,CA 95119 PHONE NO:(408)590-7565 L LICENSED CONTRACTOR'S DECLARATIONF 1 BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class L' �W '' / ` MECH RESIDENTIAL COMMERCIAL Contractor Date " ZO I hereby affirm at I am license under the provisions of Chapter 9 JOB DESCRIPTION: INSTALL NEW SERVICE MAST AND UPDATE (commencing with Section 7000)of Division 3 of the Business&Professions GROUNDING 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. I have and will maintain Worker's Compensation Insurance,as provided for by Sq.Ft Floor Area: Valuation:$450 Section 3700 of the Labor Code,for the pece of the work for which this permit is issued. rf APN Number:35903027.00 Occupancy Type: APPLICANT CERTIFICATION I 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 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. dditi Wally,the applicant understands and will comply with all non-point so c re ations per e C p rti Municipal Code,Section 9.18. / Issued by: Date: Signature Date 7 OWNER-BUILDER DECLARATION RE-ROOFS: All roofs shall be inspected prior to any roofing material being installed.If a roof is I 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: Date: Business&Professions Code) 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 I hereby affirm under penalty of perjury one of the following three HAZARDOUS MATERIALS DISCLOSURE declarations: 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. I will maintain performance of the work for which this permit is issued. compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health& I have and will maintain Worker's Compensation Insurance,as provided for by Safety Code,Section 25532(a)should I store or handle hazardous material. Section 3700 of the Labor Code,for the performance of the work for which this Additionally,should I use equipment or devices which emit hazardous air 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 I certify that in the performance of the work for which this permit is issued,I shall Health&Safe Code,S on 5505,25533,and 25534. not employ any person in any manner so as to become subject to the Worker's Compensation laws of Cal ifomia. If,after making this certificate of exemption,I Own orized g become subject to the Worker's Compensation provisions of the Labor Code,I must Date: l�-0 /4'V 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, `s,and expenses which may accrue against said City in consequence of the ARCHITECT'S DECLARATION .ing of this permit.Additionally,the applicant understands and will comply viwi 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 CITY OF CUPERTINO 6 ITEMS OF 6 PERMIT RECEIPT OPERATOR: TraciC COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN 35903027 . 00 DATE ISSUED. . . . . . . : 07/18/2011 RECEIPT #. . . . . . . . . BS000014080 REFERENCE ID # . . . : 11070114 SITE ADDRESS . . . . . : 7819 LILAC CT SUBDIVISION . . . . . . . CITY . . . . . . . . . . . . . . CUPERTINO IMPACT AREA . . . . . . OWNER BURKLUND DALE C AND MARGARET L ADDRESS 7819 LILAC CT CITY/STATE/ZIP . . . : CUPERTINO, CA 95014-4207 RECEIVED FROM . . . . : ALAN FORTIM CONTRACTOR ALAN FORTIN LIC # 27871 COMPANY LIGHTHOUSE ELECTRIC ADDRESS 236 BURNING TREE DR CITY/STATE/ZIP . . . : SAN JOSE, CA 95119 TELEPHONE (408) S90-7565 FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- - lADMIN HOURS 1 . 00 41. 00 0 . 00 41. 00 0 . 00 1BCBSC VALUATION 450 . 00 1 . 00 0 .00 1 . 00 0 .00 1BREMMISC EACH 1. 00 130 . 00 0 . 00 130 . 00 0 . 00 1BSEISMICR VALUATION 450. 00 0 .50 0 . 00 0. 50 0 .00 1EPERMITFE FLAT RATE 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 260 .50 0 . 00 260 . 50 0 . 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CASH 260 .50 --------------- TOTAL RECEIPT 260 .50 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------- 304 ROUGH ELECTRICAL 505 FINAL ELECTRICAL 'V\X GENERAL PERMIT APPLICATION MEP COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 10300 TORRE AVENUE •CUPERTINO, CA 95014-3255 MISC (408)777-3228• FAX(408)777-3333• building(rJcupertino.org CUPERTIN0 // ❑PLUMBING ❑MECHANICAL ELECTRICAL [:]MISCELLANEOUS PROJECT ADDRESS Jy' ("/ /� I ! /� 1'7 Cf APN# OWNER NAME L IIrL 13 U Z 1G G I--' PHONE L J �'7 /y/_ C E-MAIL STREET ADDRESS �.Ito i�1 ) CITY, STATE,ZIP '`�( q So /4 FAX C. C CONTACT NAME n { PHONE E-MAIL _I L V+Itl L0 I STREET ADDRESS i,r 7 i� _ /J 0 J C CITY,STATE, ZIP �� FAX 14 ❑OWNER ❑ OWNER-BUILDER ❑ OWNERAGENr//r T`� 1_ �CNTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT CONTRACTOR NAME 4 ,/U/ LICENSE NUMBER 4 S-()S-21 LICENSE TYE J/ BUS.LIC# t7 I COMPANY NAME E MAIL FAX STREET ADDRESS 967 n -064 / ' 122 CITY,STATE,ZIP IC, :� (`l G PHONE �� 7�- C- ARCHIT'ECT/ENGINEER NAME LICENSE NUMBER 1 BUS.LIC# (O J COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE 0 YES JSE OF SFD or DUPLEX ❑ MULTI-FAMII Y PROJECT IN WII DLAND ❑ YES PROJECT iN ❑YES IS THE BLDG AN BUILDING: ❑COMMERCIAL URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑NO EICHLER HOME? DESCRIPTION OF WORK t/ re` 2 t 1� 'rZ e (� `'o 170 uH. 4 / TOTAL VALUATION: +�� 61 S/O RECEIVED BY: By my signature below,I certify to each of the following: I am the prope r or authorized agent to act on the property owner's behalf. I have read this application and the information I have provided is correct., have read Descnp Ion of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating to building construC n:,l authorizer ,r entativ of Cupertino to enter the above-identified property for inspec/tion pu{poses. Signature of Applicant/Agent: /- o Date: I/t(T� l/ SUPPLEMENTAL INFORMATION REQUIRED ��OFFICE USE ONLY CJ OVER-THE-COUNTER ❑ EXPRESS Y U w ❑ STANDARD U < ❑ LARGE ❑ MAJOR MEPMiscApp_2011.doc revised 06121/11