10080150 CITY OF CUPERTINO BUILDING PERMIT
fBUILDING ADDRESS: 20803 ALVES DR CC NTRACTOR:SHRADER ELECTRIC, PERMIT NO: 10080150
INC
(OWNER'S NAME: YMCA OF SILICON VALLEY IOS 3 FLORENCE WAY DATE ISSUED:08/20/2010
NER'S PHONE: 4083711526 CAMPBELL,CA 95008 PHONE NO:(408)371-1526
❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL= COMMERCIAL
License Class (, I() Li,.# gS) O49 R ZMOVE 20 EXISTING FIXTURES AND REPLACE WITH 16
Contractor RA9tcA EtC-C't�ttC NEW LIGHTING FIXTURES POOL ROOM,REPAIR
Skl Date 2 %(� DE►MAGED
I hereby affirm that I am licensed under the provisions of Chapter 9 W[REMOLD IN FITNESS ROOM
(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:$9000
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 APV Number:32632039.00 Occupancy Type:
permit is issued.
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED
correct.I agree to comply with all city and county ordinances and state laws relating WITHIN 180 DAYS OF PERMIT ISSUANCE OR
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save 180 DAYS FROM LAST CALLED INSPECTION.
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the / ' / '" x�
granting of this permit. Additionally,the applicant understands and will comply Iss ied by: /'I tw- Date: ` "C
with all -point source rJegulations er the Cupertino Municipal Code,Section
9.18.
c> .2 0 w RE-ROOFS:
Signature Date O All roofs shall be inspected prior to any roofing material being installed.If a roof is
instilled without first obtaining an inspection,I agree to remove all new materials for
insl ection.
U OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of Sig nature of Applicant: Date:
the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
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,
Business&Professions Code)
I,as owner of the property,am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE
construct the project(Sec.7044,Business&Professions Code). I hs ve read the hazardous materials requirements under Chapter 6.95 of the
California Health&Safety Code,Sections 25505,25533,and 25534. 1 will
I hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
declarations: Hes Ith&Safety Code,Section 25532(a)should I store or handle hazardous
I have and will maintain a Certificate of Consent to self-insure for Worker's mai erial. Additionally,should I use equipment or devices which emit hazardous
Compensation,as provided for by Section 3700 of the Labor Code,for the air :ontaminants as defined by the Bay Area Air Quality Management District I
performance of the work for which this permit is issued. will maintain compliance with the Cupertino Mu icipal Code,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,S tions 2550 553 nd 25534.
Section 3700 of the Labor Code,for the performance of the work for which this C
permit is issued.
Owner or authorized agent: Wim, ate. b C)
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
Compensation laws of California. If,after making this certificate of exemption,I CONSTRUCTION LENDING AGENCY
become subject to the Worker's Compensation provisions of the Labor Code,I must I he-eby affirm that there is a construction lending agency for the performance of
forthwith comply with such provisions or this permit shall be deemed revoked. wor c's for which this permit is issued(Sec.3097,Civ C.)
Lender's Name
APPLICANT CERTIFICATION Lender's Address
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
upon the above mentioned property for inspection purposes.(We)agree to save
�mnify and keep harmless the City of Cupertino against liabilities,judgments, ARCHITECT'S DECLARATION
,,and expenses which may accrue against said City in consequence of the I un ierstand my plans shall be used as public records.
granting of this permit.Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section Lice used Professional
9.18.
Signature Date
CITY OF CUPERTINO
5 ITEMS OF 5 PERMIT RECEIPT OPERATOR: SylviaM
COPY # 1
Sec: Twp: Rng: Sub: Blk: I,ot:
APN . . . . . . . . : 32632039. 00
DATE ISSUED. . . . . . . : 08/20/2010
RECEIPT #. . . . . . . . . : BS000011239
REFERENCE ID # . . . : 100803.50
SITE ADDRESS . . . . . : 20803 ALVES DR
SUBDIVISION . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . . .
OWNER YMCA C,F SILICON VALLEY
ADDRESS 20803 ALVES DR
CITY/STATE/ZIP . . . : CUPERTINO, 95126-1704
RECEIVED FROM . . . . : SHRADER ELECTRIC
CONTRACTOR . . . . . . . : DENNIE D SHRADER, JR LIC # 31866
COMPANY SHRADER ELECTRIC, INC
ADDRESS 1093 FLORENCE WAY
CITY/STATE/ZIP . . . : CAMPBELL, CA 95008
TELEPHONE (408) 371-1526
FEE ID UNIT QUANTITY AMOLNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
1BCBSC VALUATION 9, 000 . 00 1. 00 0 .00 1. 00 0. 00
1BREMFIXT NO. FIXTURES 16 . 00 63 . 00 0 . 00 63 . 00 0. 00
1BREMMISC EACH 1 .00 126 . 00 0 . 00 126 . 00 0 . 00
IEPERMITFE FLAT RATE 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 274 . 00 0 .00 274 . 00 0. 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CHECK 274 . 00 2427
---------------
TOTAL RECEIPT 274 . 00
CITY OF CU PERTINO
FEE ESTIMATOR- BUILDING DIVISION
ADDRESS: DATE: REVIEWED BY:
APN: BP#: *VALUATION: Iso
%PERMIT TYPE: Electrical Permit PLAN CI[ECK TYPE: Alteration /Addition/ Repair
PRIMARY SFD or Duplex 101.41. PENTAMATION 1 REAP11
USE: 1I'Z Ot1K.tttt;�: PERMIT TYPE:
wORK Remove 20 existing fixtures and replace with 16 iew lighting fixtures pool room. Repair damaged
SCOPE wiremold in fitness room.
APPLIANCE/EQUIP TYPE FEE ID QTY BP FEES
Fixtures, Lighting 1BREMFIXT 16 $63
Special Circuits 1BREMMISC 1 $126
TOTALS: $189.00
Phel;,!b, Phm t'lw(A Elec.Plan Check 0.0 1 hrs $0.00
ti1r,_„ P�t,ttit f'c _ PIr;az1 Ptra.,lit/,"C' Elec.Permit Fee: IEPERMIT
Olhc r Ph mt"h1 sl, Other Elec.Insp. 10--01hrs t $42.00
NOTE: Thesefees are based on the preliminary information availai rle and are only an estimate. Contact the De t or addn'l info,
FEE ITEMS (Fee Resolution 09-051 Ef'. 711170) FEE QTY/FEE MISC ITEMS
1,14111 Check Vec:
slipp1 Pt'/,-ee F71
PME Plan Check: $0.00
supp/. 11isp FCC
PME Unit Fee: $189.00
PME Permit Fee: $42.00
Canso-11"non Tay
Work Without Permit? 0 Yes 0 No $0.00
1'ltlrtrtltt�,r 1 Esc'.>:
Travel Documentation Fee: ITRA VDOC $42.00
S"I1 or1.; ,11oti111r Fee: Select an Administrative Item
Bldg;Stds Commission Fee: $0.00
SUBTOTALS: $273,00T $0.00 TOTAL FEE: $273.00
Revised: 8/17/2010
Building Department
City Of Cupertino
10300 Torre Avenue
Cupertino, CA 95014-3255
Telephone: 408-777-3228
C U P E RT I N O Fax: 408-777-3333
CONTRACTOR/ SUBCONTRACTOR LIST
JOB ADDRESS: 10903 L U C-S 7(Z . PERMIT#
OWNER'S NAME: '/Mc fs eft 514 t<0Yb tit Ugtty, PHONE# - /5" -2-6
GENERAL CONTRACTOR: 5AR,40 fyk CleC7(tta BUSINESS LICENSE# 3 / SGL
ADDRESS:/093 fl-oREyUC L-, A,7 <'hmVletit. C,k, Upi CITY/ZIPCODE: Cartifl3tt, (N. ?SdU 01
*Our municipal code requires all businesses working in the city to have a City of Cupertino business license.
NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE
GENERAL CONTRACTOR AND L SUBCONTRACT RS HAVE OBTAINED A CITY OF CUPERTINO
BUSINESS LICENSE.
I am not using any subcontractors:
Signatu re Date
Please check applicable subcontractors and complete the following information:
j/ SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets & Millwork
Cement Finishing
Electricals-/(rZ
Excavation
Fencing
Flooring/Carpeting
Linoleum /Wood
Glass / Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Painting/Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/Contractor Signature Date
PT,
-- `� CITY OF CU13ERTINO
CUPEkTINO GENERAL BUILDING
PERMIT APPLICATION FORM
//1��' /'
APN # Date:
Building Address:
d8'U3 1) LQU S 1
Mailing Address (if different from building address):
Are Hazardous Materials being used as part of this pro ect? Yes No
HOA: (Exterior work only) Yes ❑ No ❑ If yes, provide letter from HOA
Owner's Name: Phone#:
V �1n C P� c�� S �. c oxo �I P�L tE q a$
Contractor: 1 Phone:
5h R A (--6L !�GC--(FRI Fax: q O'R 3'1 l - 16),7
Contractor License#: < <U L 9S"/ O 4 9
Cupertino Business License#:
ContaPhone:
tENN\1 S141ZP PE C Fax:
.residential Fj Commercial
Job Description: t-c, XC CX%5TING r IX'tWQr5 R-�v.bu kv fitwc,
1 j+c ry �)1A tv+ � G E O
Building Permit Info:
Bldg ❑ Elect Plum:) ❑ Mech ❑
Type of Construction (Usage Class): Occupancy Type:
1-A, 1-B ❑ IUIII/V-A ❑ IUIII B, IV-HT, V-B _
Valuation: Square Footage:
Project Size: Express ❑ Standard ❑ Large ❑ Major ❑
Green Building: Please complete relevant portion of the Green B ' ding/LEED Checklist& attach it
to the application or if applicable, include in plan set & the sheet index.
Doints Achieved: '
-,'or help, contact Build it Green at www.builditgreen.or '
Revised 07/14/09