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09100124 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 20900 STEVENS CREEK BLVD CONTRACTOR:TBD-TO BE DETERMINED PERMIT NO:09100124 OWNER'S NAME: UNION CHURCH OF CUPERTINO DATE ISSUED: 10/20/2009 k ER'S PHONE: 4082524478 PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATIONr Z License Class Lic.# BUILDING PERMIT INFO: BLDG ELECT PLUMB MECH I- RESIDENTIAL f- COMMERCIAL Contractorg V�iL1',��Ci. Date 7/� I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:TEMP POWER POLE;B VERSOZA,INC.PD FOR (commencing with Section 7000)of Division 3 of the Business&Professions BUS LIC Code and that my license is in full force and effect. 10/16/09 GOOD THRU 10/31/10 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:$300 Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. APN Number:35908024.00 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. Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. Issued{,,,,. Date(}- � SignatureDate ` O OP y ❑ 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&Safety Code,Sections 25505,25533,and 25534. not employ any person in any manner so as to become subject to the Worker's Compensation laws of California. If,after making this certificate of exemption,I Owa t t: become subject to the Worker's Compensation provisions of the Labor Code,I must Date: 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 nify and keep harmless the City of Cupertino against liabilities,judgments, c.. -,and expenses which may accrue against said City in consequence of the ARCHITECT'S DECLARATION granting of this permit.Additionally,the applicant understands and will comply with 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 4 ITEMS OF 4 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN . . . . . . . . : 35908024 . 00 DATE ISSUED. . . . . . . : 10/20/2009 RECEIPT #. . . . . . . . . : BS000008976 REFERENCE ID # . . . 09100124 SITE ADDRESS . . . . . : 20900 STEVENS CREEK BLVD SUBDIVISION . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . OWNER UNION CHURCH OF CUPERTINO ADDRESS . . . . . . . . . . : 20900 STEVENS CREEK BLVD CITY/STATE/ZIP . . . : CUPERTINO CA, CA 95014-2121 RECEIVED FROM . . . . : NANCY VERSOZA 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 ---------- ------------- ---------- ---------- ---------- ---------- ---------- 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 42 .00 0 . 00 42 . 00 0 .00 1ERT<200 UNITS 1. 00 42 .00 0 . 00 42 . 00 0 . 00 ---------- ---------- ---------- ---------- TOTAL PERMIT 85 .50 0 .00 85.50 0 . 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CREDIT CARD 85.50 AMEX --------------- TOTAL RECEIPT 85 .50 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 402 TEMPORARY POWER 0 ��1 CITY OF CUPERTINO TEMP POWER CUPEkTINO PERMIT APPLICATION FORM APN # Date, -2- Building 2Building ddr'7 _ 4c), 64 C15,91tf QQwner's Name: Phone#: mon cAawa 4z) 9 -d 5j - gL479 Contractor: Phone #:510 , Lf 15, cOnD 12'sn'k OR Fax #: 5 t - 3 7��(7 Contact: Phone #: Q RJc* �� '� tD. , 3)4 Contractor License #: 2 Cupertino Business License #: / Job Description: Residential El Commercial Valuation (cost of project): Type of Construction: N/A Quantity Fee ID Fee Description Fee Group Permit Type 1 ERT>1 K Res. Temp Power>I K E 1REAP14 Amps 1 ERT<200 Res. Temp.Power<200 E Amps 1 ERT2001 K Res. Temp Power 200-1 K E Amps 1 EPERMITFE Electric Permit Issuance E i 1 ELCPLNCK Electric Plan Check E 1BCBSC Cal Bldg Standards B ALL PERMIT Commission Fee TYPES 1BSEISMICR Seismic Residential B 1TRAVDOC Travel & Documentation B Fee Revised 01/07/09 Community Development 10300 Torre Avenue y„. Cupertino CA 95014 Telephone(408)777-3228 CITY OF Fax(408)777-3333 .,UPEkTINO Building Department OB ADDRES • PERMIT # O go 0k4u094o I 0 7 fl�7co OWNER'S NAME:"1 0L' PHONE # 47 Y GENERAL CONTRACTOR 8 LfWDJ4 , FAX # I am not using any subcontractors: IN?,*(9 Signature Date Please check applicable subcontractors and complete the following information: SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets &Millwork Cement Finishing Electrical Excavation Fencing Flooring: Carpeting Linoleum/ Wood Glass/ Glazing Heating Insulation Landscaping Lathing Masonry Ornamental Sheet Metal Painting/ Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile bw-Zer/Contra for Signature Date