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10080122 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 21914 HERMOSA AVE CONTR ACTOR:R.KIRK DEVELOPMENT, PERMIT NO: 10080122 INC OWNER'S NAME: JAMES R&PAMELA L COURTRIGHT PO BO)i 25 DATE ISSUED:08/18/2010 i'NER'S PHONE: 4082554147 SAN M/ATIN,CA 95046 PHONE NO:(408)686-1199 9 LICENSED CONTRACTOR'S DECLARATIONF BUILD[NG PERMIT INFO: BLDG ELECT PLUMB License Class7jj:r Lic.# ( F � n MECH RESIDENTIAL COMMERCIAL Contractor Date O I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:TEMP POWER,POWER POLE OVERHEAD (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 FI oor Area: Valuation:$200 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. 1161- APN Number:35716048.00 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 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, 181) 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 the Cupertino Municipal Code,Section Issued JA*:- I'�� _� Date(� 9.18. Signature / — Date 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 inspecticn. the following two reasons: 1,as owner of the property,or my employees with wages as their sole compensation, Signatur;of Applicant: Date: will do the work,and the stricture 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 r4!ad 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 complia ice with the Cupertino Municipal Code,Chapter 9.12 and the Health& performance of the work for which this permit is issued. Safety C ode,Section 25532(a)should I store or handle hazardous material. I have and will maintain Worker's Compensation Insurance,as provided for by Additim sally,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 contami ants 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 ti Safety Code,Sections 25505,25533,and 25534. not employ any person in any manner so as to become subject to the Worker's Owne r alithoriz gent: Compensation laws of California. If,after making this certificate of exemption,I / Date: 9 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 constriction lending agency for the performance of work's APPLICANT CERTIFICATION for whic r this permit is issued(Sec.3097,Civ C.) I certify that I have read this application and state that the above information is Lender';Name correct.I agree to comply with all city and county ordinances and state laws relating to building constriction,and hereby authorize representatives of this city to enter Lender';Address unon the above mentioned property for inspection purposes.(We)agree to save unify and keep harmless the City of Cupertino against liabilities,judgments, 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 I undersi and 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 CITY OF CUPERTINO 4 ITEMS OF 4 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot : APN 35716048 .00 DATE ISSUED. . . . . . . : 08/18/2C10 RECEIPT #. . . . . . . . . BS000011209 REFERENCE ID # . . . : 10080122 SITE ADDRESS . . . . . : 21914 HERMOSA AVE SUBDIVISION . . . . . . CITY CUPERT I YO IMPACT AREA . . . . . . OWNER JAMES R & PAMELA L COURTRIGHT ADDRESS 21914 HERMOSA AVE CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM . . . . : ROBERT DIANTIA CONTRACTOR . . . . . . . : RANDALL KIRK LIC # 31716 COMPANY R. KIRK DEVELOPMENT, INC ADDRESS PO BOX 25 CITY/STATE/ZIP . . . : SAN MAR-IN, CA 95046 TELEPHONE . . . . . . . . : (408) 6f;6-1199 FEE ID UNIT QUANTITY AMOUNT' PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ----------- ---------- ---------- ---------- 1BCBSC VALUATION 200 . 00 :. .00 0. 00 1.00 0 .00 lEPERMITFE 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 12'7 .00 0. 00 127. 00 0 .00 METHOD OF PAYMENT AMOUNT RIs'FERENCE NUMBER ----------------- --------------- --- ----------------- CREDIT CARD 127 . 00 MC --------------- TOTAL RECEIPT 127 . 00 VOICE ID DESCRIPTION 'IOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 402 TEMPORARY POWER CITY OF CUP'ERTINO TEMP POWER CUPIT TINO PERMIT APPLICATION FORM APN # Date: Building Address: ,ZZy141 Owner's Name: Phone #: _ 2 S -5 Contractor: Phone#: Fax #: Contact: Phone #: Contractor License #: �j Cupertino Business License —7 L Job Description: c dD Residential Commercial ❑ Valuation (cost of project): Type of Constructio : N/ Quantity Fee ID Fee Description Fee Group Permit Type 1 ERT>I K Res. Temp Power>1 K E 1REAP14 Amps IERT<200 Res. Temp Power<200 E Amps 1 ERT2001 K Res. Temp Power 200-1 K 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 & Document,-.tion B Fee Revised 01/07/09 CITY OF CUPE RTINO FEE ESTIMATOR-BUILDING DIVISION ADDRESS: DAT).: REVIEWED BY: APN: BP#: 'VALUATION: $200 %PERMIT TYPE: Electrical Permit PLAN CHECK TYPE: Alteration/Addition/ Repair PRIMARY SFD or Duplex 1'O7,1111. PENTAMATION 1REAP14 USE: p /'LOOKSfal PERMIT TYPE: WORK SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY BP FEES Temporary Power 1 ERT<200 1 $42 TOTALS: $42.00 Plolnb 1 hrw Elec.Plan Check 1 0.0 1 hrs $0.00 idr,h 1'rr,ir"t�c>�; I tit�h. Perrrzl/f a=: Elec.Permit Fee: IEPERMIT trlf> t1lb-�I hor"/,lov,_ Other Elec.Insp. Fo.0 hrs $42.00 11�cla I�t�2 I�z� Phmrb. Ir0p. FA, 1IeC Inn, 1"'c' NOTE. Thesefees are based on the preliminary in ormation available and are only an estimate. Contact the De t or addn'1 info. FEE ITEMS (Fee Resolution 09-051 Efff. FEE Q-CY/FEE MISC ITEMS Plug C'/lcc:k slipp/_ PC`1"Ce PME Plan Check: $0.00 1'c'r7f1r't Fce: slfp /l hop PME Unit Fee: $42.00 PME Permit Fee: $42.00 t_'r,rz�trrrction 1 u.a 1 'oz�sfl<.r.rl licitv`ew FCC' Work Without Permit? 0 Yes 0 No $0.00 PlrrrtrriEa<�f�'t�c.�: Travel Documentation Fee: ITRAVDOC $42.00 A .Sirmig l/oiioir P"'c: Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $1.00 SUBTOTALS: $127.00 $0.00 TOTAL FEE: $127.00 Revised: 8/17/2010 Building Department —cis City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014-3255 Telephone: 408-777-3228 CUPERTINO Fax: 408-777-3333 CONTRACTOR/ SUBCO'vTRACTOR LIST JOB ADDRESS: 2 / �j�c,Q�,, EBUSINESS # d�Z�' OWNER'S NAME: - ,e, Y GENERAL CONTRACTOR: „�rL LICENSEADDRESS: PCODE: *Our municipal code requires all businesses working in the cit} 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 SUBCONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE. I am not using any subcontractors: ate S' nature Please check applicable subcontractors and complete the following information: &/ SUBCONTRACTOR BUSINESS NA VIE 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