09080021 CITY OF CUPERTIN O BUILDING PERMIT
BUILDING ADDRESS: 21885 MEADOWVIEW LN CONTRACTOR:G E RICHARDSON PERMIT NO:09080021
ELECTRIC
V`vER'S NAME: AXELSON CORDELL H AND DONNA 1 15466 LOS GATOS BLVD DATE ISSUED:08/05/2009
0,, ER'S PHONE: 4088219437 LOS GATOS,CA 95030 PHONE NO:(408)438 1192
P/ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class G^{D Lic.# A!�s?
,.,, � MECH RESIDENTIAL COMMERCIAL
Contractor L* Z�t��t t FL. Date q d
1 hereby affirm that 1 am licensed under the provisions of Chapter 9 JOB DESCRIPTION:100 AMP MAIN SERVICE UPGRADE TO 200 AMP;
(commencing with Section 7000)of Division 3 of the Business&Professions CONTRACTOR RENEWD BUS LIC 8/5/9(#29764)
Code and that my license is in full force and effect.
1 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:$3000
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
APN Number:32645022.00 Occupancy Type:
permit is issued.
APPLICANT CERTIFICATION
1 certify that 1 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 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 7
with all non-point source regulations per the Cupertino Municipal Code,Section Issued by:" Date:
9.18. ,
Si- -cure Date 67-.5
.11
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
1 hereby 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)
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).
HAZARDOUS MATERIALS DISCLOSURE
1 hereby affirm under penalty of perjury one of the following three
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 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
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 or auto 'zed agent: �^ t
Compensation laws of California. If,after making this certificate of exemption,I Date: Lt _
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
L, .e above mentioned property for inspection purposes.(We)agree to save
iN iily and keep harmless the City of Cupertino against liabilities,judgments, ARCHITECT'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
o v 'a0�-1
9�
b
y CITY OF CUPERTINO
CUPEI�TINO GENERAI-_J BUILDING
PERMIT APPLICATION FORM
APN# Date:
2Abq ,�
Building Address:
1 C et 4L,
Mailing Address (if different from building address):
Are Hazardous Materials being used as part of this project? Yes ❑ No
HOA: Exterior work only) Yes ❑ No [1 If yes,provide letter from HOA
Owner's Name: Phone#:
if# yv9 .— qct
Contractor: Phone:
Fax: ��_�' - Y 3 R
Contractor License#:
Cupertino Business License#: �17
(eo 1�
Contact: Phone:
1 eC.r , C k f.J01- 1 Fax:
Residential Commercial
Job Description:
fic
Building Permit Info:
Bldg ❑ Elect (r Plumb ❑ Mech ❑
Type of Construction (Usage Class): Occupancy Type:
1-A, 1-B ❑ II/III/V-A ❑ IUIII B, IV-HT, V.-B pw, t 1,
Valuation: Square Foota :
.25 c � 41
Project Size: Express ❑ Standard E10" Large ❑ Major ❑
Green Building: Please complete relevant portion of the Green Building/LEED Checklist& attach it
to the application or if applicable, include in plan set& the sheet index.
Points Achieved:
For help, contact Build it Green at www.builditgreen.or
Revised 07/14/09
CITY OF CUPERTINO
Cin of GENERAL BUILDING APPLICATION
CUPEkTINO FEE SCHEDULE
Quantity/Sf Fee ID Fee Description Fee Permit Type
Group 1GENRES or
1GENCOM
1STUCOAP Stucco A:)plications (up to 400 sf) B
additional stucco application
1 WINREP Replacement windows/sliding glass B
door (ea 8 windows)
1 WINMEWSTR New Wir.dow-structural shear B
wall/mase (includes plan ck fee)
1 EPERMITFEE Electrics' Permit Fee E
1 MPERMITFEE Mechanii;al Permit Fee M
1PPERMITFEE Plumbing;Permit Fee P
1 ELCPLNCK Stand Al ane Electric Pln Ck(hourly) E
1MECPLNCK Stand Alone Mechanical Pln Ck(hrly) M
1PLMBLNCK Stand Alone Plumbing Pln Ck(hrly) P
1 STPLNCK-(3 Hr Min Standard Plan Check(when no E/M/P) B
when not over counter) hourly- and alone
I 1BCBSC Cal Bldl;Standards Commission Fee B ALL PERMIT
TYPES
1BSEISMICR Seismic Residential B
1BSEISMICO Seismic Commercial B
1TRAVDOC Travel &Documentation B
1BUSLIC Busines3 License B
5 of 5
Community Development
' 10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CM OF Fax(408)777-3333
;,UPEkTINO
Building Department
JOB ADDRESS: � PERMIT # O O�O� r�
�Sr Mc w v Z w U K . vC
OWNER'S NAME: ?k�z PHONE # Y0 ) 7 2 ?
GENERAL CONTRACTOR: FAX #
yGr
I am not using any subcontractors:
gnature Date
Please check applicable subcontractors and corn lete 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
Owne Contractor Signature tate