11010017 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 20776 FARGO DR CONTRACTOR:ROBERTS CONSTRUCTION PERMIT NO: 11010017
OWNER'S NAME: JOHN&LINDA ADAMS 16636 FARLEY RD DATE ISSUED:01/03/2011
R"'NER'S PHONE: 4082550402 LOS GATOS,CA 95032 PHONE NO:(408)356-2185
L LICENSED CONTRACTOR'S DECLARATION [_ r
BUILDING PERMIT INFO: BLDG ELECT PLUMB
License ClassLi,# 2
MECH r— RESIDENTIAL r— COMMERCIAL�
Contractor�OA£ rS 6VA(5—,4A I1Abate
I hereby affirm that I am licensed under the.provisions of Chapter 9 JOB DESCRIPTION:TEMP POWER POLE FOR CONSTRUCTION
(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:$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. APN Number:32630124.00 Occupancy Type:
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above informatJis/vl
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 a Cupertino Municipal Code,Section Issued by:t �' Date:
9.18.
Signature Date I
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
I 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)
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. I 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
permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
P Health&Safety Code,Sections 25505,25533,and 25534.
I 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 OV2er or authorized agent
Compensation laws of California. If,after making this certificate of exemption,I Date: �1
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.)
I 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
`s,and expenses which may accrue against said City in consequence of the
ing of this permit.Additionally,the applicant understands and will comply I understand my plans shall be used as public records.
�,ii-in all non-point source regulations per the Cupertino Municipal Code,Section
9.18. Licensed Professional
Signature Date
CITY OF CUPERTINO
5 ITEMS OF 5 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot :
APN . . . . . . . . : 32630124 . 00
DATE ISSUED. . . . . . . : 01/03/2011
RECEIPT #. . . . . . . . . : BS000012381
REFERENCE ID # . . . : 11010017
SITE ADDRESS . . . : 20776 FARGO DR
SUBDIVISION . . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : JOHN & LINDA ADAMS
ADDRESS . . . . . . . . . . : 20776 FARGO DR
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
RECEIVED FROM . . . . : DAVID ROBERTS
CONTRACTOR . . . . . . . : DAVE ROBERTS LIC # 32236
COMPANY . . . . . . . . . . : ROBERTS CONSTRUCTION
ADDRESS 16636 FARLEY RD
CITY/STATE/ZIP . . . : LOS GATOS, CA 95032
TELEPHONE . . . . . . . . : (408) 356-2185
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
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 42 . 00 0.00 42 . 00 0 .00
1ERT<200 UNITS 1. 00 42 . 00 0 . 00 42 . 00 0 .00
1TRAVDOC FLAT RATE 1. 00 42 .00 0 . 00 42 . 00 0 .00
---------- ---------- ---------- ----------
TOTAL PERMIT 127 .50 0.00 127.50 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CREDIT CARD 127 .50 VISA
---------------
TOTAL RECEIPT 127.50
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
402 TEMPORARY POWER
CITY OF CUPERTINO
FEE ESTIMATOR—BUILDING DIVISION
ADDRESS: 20776 fargo dr. DATE: 01/03/2011 REVIEWED BY: bobs.
APN: BP#: `VALUATION: $500
J�PIERMIT TYPE: Electrical Permit PLAN CHECK TYPE: Alteration/Addition/ Repair
PRIMARY SFD or Duplex I C1 11. PENTAMATION 1 REAP14
USE: p Fl,001t .1Rk,'I. PERMIT TYPE:
WORK temp power
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Temporary Power 1 ERT<200 100 Amps $42
TOTALS: $42.001 1
�Ltcar. F'1ac1 C'kir k r�s;Fr�;_I'�`�fJr �csz Elec.Plan Check 0.0 hrs $0.00
Elec.Permit Fee: IEPERMIT
C)rTtcr afecr't. Irr.rt>. Phfrrlb ff;:7, Other Elec.Insp. El hrs $42.00
alc(h. In�p. VCC: p zrrnh. li itz t< l iec. Ir2s; Ire
NOTE: These-Ts are based on the preliminary in ormation available and are only an estimate. Contact the De t or addh 7 info.
FEE ITEMS (Fee Resohition 09-05I Eff 7/1110) FEE QTY/FEE MISC ITEMS
/Tarr ("11CCk Fee:
Supp/. 1"(1,Fee
PME Plan Check: $0.00
Perinit Fet,,.
Sapp/. Irrsp Fee
PME Unit Fee: $42.00
PME Permit Fee: $42.00
(7onstr uc°iion Kix F
tc:ou:sficol licview Fcc:
Work Without Permit? 0 Yes No $0.00
Plcrrtrrin,�„r l�'ec=s:
Travel Documentation Fee: ITRAVDOC $42.00
Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item
Bldg Stds Commission Fee: 1BCBSC $1.00
SUBTOTALS: $127.50 $0.00 TOTAL FEE: $127.50
Revised: 12/07/2010
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: 2-0 7'7 r-A-/LL.0 02, PERMIT#
OWNER'S NAME: A 0A 'wl <N PHONE#
GENERAL CONTRACTOR: 12D t;n.--jS CuS%t,+�71 BUSINESS LICENSE# ZZ 3
ADDRESS: bs-6r4V;- I CITY/ZIPCODE: C ,s> GA O 'Z
*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 SUB ONT CTORS HAVE OBTAINED A CITY OF CUPER/TINO
BUSINESS LICENSE. t / - 3 - /r
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
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
Owner/Contractor Signature Date
CITY OF CUPERTINO
E TEMP POWER
CUPEkTINO PERMIT APPLICATION FORM
APN # Date:
32- C,-S 0-1 -Z 9 . DD
Building Address:
2D fi�t�D far T) Cv f6hp Ck 15,DI H
Owner's Name: Phone #:
,JoWi ark (,ir& AAams (q6g) 255 N 1D2-
Contractor:
DZContractor: I MU rlev Cw baWS,(A Phone #: (qo ��(p —Z I$15
46(,tS cwsS vUC6u) x6052
Fax #: y u(DU
Contact: Phone #: (qTA) 2.10 —(4365
D0-4%a ?DkI(Its
Contractor License #: �9 �6 Z
Cupertino Business License #: 3 223 6
Job Description: -�fyy,?MfJ VUjW ode {-pr msLTUc3co
Residential 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
IERT<200 Res. Temp Power<200 E
Amps
IERT2001K Res. Temp Power 200-1K E
Amps
IEPERMITFE Electric Permit Issuance E
IELCPLNCK Electric Plan Check E
1BCBSC Cal Bldg Standards B ALL PERMIT _
Commission Fee TYPES
1BSEISMICR Seismic Residential B
1 TRAVDOC Travel & Documentation B
Fee
Revised 01/07/09