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11020024 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10208 COLD HARBOR AVE CONTRACTOR:R W CONSTRUCTION PERMIT NO: 11020024 OWNER'S NAME: EUGENE WEST 315 TABOR DR DATE ISSUED:02/07/2011 OWNER'S PHONE: 4087811854 SCOTTS VALLEY,CA 95066 PHONE NO:4083956446 L LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG F— ELECT T_ PLUMB F_ License Class Lie.# �f�i� �� MECH r RESIDENTIAL r— COMMERCIAL F_ Contractor Date a"7 L/ I hereby affirm that I am li nsed under the provisions of Chapter 9 JOB DESCRIPTION:TEMP POWER POLE (commencing with Section 7000)of Division 3 of the Business&Professions **SEE NOTES** 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:$900 Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. APN Number:36909039.00 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 regulati er the ertino Municipal Code,Section 9.18. � Issued by: Date:��7' I Signature Date "/ 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 declarations: HAZARDOUS MATERIALS DISCLOSURE 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 permit is issued. 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 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 Ow ere au ( e� 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. 11 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, c- and expenses which may accrue against said City in consequence of the ng of this permit.Additionally,the applicant understands and will comply ARCHITECT'S DECLARATION ,A—i 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 5 ITEMS OF 6 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN . . . . . . . . : 36909039. 00 DATE ISSUED. . . . . . . : 02/07/2011 RECEIPT # . . . . . . . . . BS000012656 REFERENCE ID # . . . : 11020024 SITE ADDRESS . . . . . : 10208 COLD HARBOR AVE SUBDIVISION . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . OWNER EUGENE WEST ADDRESS 10208 COLD HARBOR AVE CITY/STATE/ZIP . . . : CUPERTINO CA, CA 95014 RECEIVED FROM . . . . : R W CONSTRUCTION CONTRACTOR . . . . . . . : WOOSLY, RICHARD LIC # 20913 COMPANY . . . . . . . . . . : R W CONSTRUCTION ADDRESS . . . . . . . . . . . 315 TABOR DR CITY/STATE/ZIP . . . : SCOTTS VALLEY, CA 95066 TELEPHONE . . . . . . . . : 4083956446 FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- ---------- 1BCBSC VALUATION 900 . 00 1. 00 0 . 00 1 . 00 0 . 00 1BSEISMICR VALUATION 900 . 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 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 402 TEMPORARY POWER CITY OF CUPERTINO FEE ESTIMATOR- BUILDING DIVISION ADDRESS: 10208 Cold Harbor DATE: 02/07/2011 REVIEWED BY: jsg APN: BP#: *VALUATION: Iso PERMIT TYPE: Minor Building Permit PLAN CHECK TYPE: Temporary Power SFD or Duplex PENTAMATION 1REAP14 PERMIT TYPE: WORK Temp power pole SCOPE APPLIANCE/EQUIP TYPE FEE ID AMPS VOLTS BP FEES Service(incl. Temp. Power) 1 ERT<200 100 <=600 $42 F '_cElec.Permit Fee: IEPERMIT C�a.�� Iitr Or"�. f�,�._1�p' $42.00 NOTE: Thesefees are based on the preliminary information available and are only an estimate. Contact the De t or addh7 info. FEE ITEMS (Fee Resolution 09-051 Etf. 7%1%10) FEE QTY/FEE MISC ITEMS Phin Chii c /"('i 77 /"cc f71t{T 7'I+.- Vc h 1((�C:'#°fl'tlt' PME Unit Fee: $42.00 PME Permit Fee: $42.00 t' r1iLStt't1t'It�ft? I�wT: Work Without Permit? 0 Yes E) No $0.00 T'Icrrtlti,r,;;T f��E g: Travel Documentation Fee: ITRAVDOC $42.00 A .5`ironJ' ;tfotbjll 1��''; Select an Administrative Item Bldg Stds Commission Fee: $0.00 SUBTOTALS: $126.00 $0.00 TOTAL FEE: 1 $126.00 Revised: 01/15/2011 I ( C-"�2 �-y CITY OF CUPERTINO TEMP POWER CUPEkTINO PERMIT APPLICATION FORM APN # Date:�) 0 () , q Building Address: U� Owner's Name: Phone #: Contractor: Phone #: 41df 2 --/ s e y , W� c�NS�ru�I ^' Fax #: S3/ 3�'6� � Contact: Phone #: Contractor License #: Cupertino Business License #: Job Description: Residential Commercial ❑ Valuation (cost of project): qjj, Type of Construction: N/A Quantity Fee ID Fee Description Fee Group Permit Type IERT>1K Res. Temp Power>1K E 1REAP14 Amps 1ERT<200 Res. Temp Power<200 E Amps IERT2001K Res. Temp Power 200-1K E Amps IEPERMITFE Electric Permit Issuance E 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