10040165 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 21111 RAINBOW DR SJ PMP STATN CONTRACTOR:SAN JOSE WATER PERMIT NO:10040165
COMPANY
NAME: SAN JOSE WATER COMPANY
110 W TAYLOR ST DATE ISSUED:04/28/2010
SAN JOSE,CA 95110 PHONE NO:
0vvNER'S PHONE: 4083160282
❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class Lic.# MECH RESIDENTIAL r- COMMERCIAL
Contractor Date
JOB DESCRIPTION:REPLACED PG&E METER SOCKET
I hereby affirm that I am licensed under the provisions of Chapter 9
(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:$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 APN Number:36210001.SJPMPSTN Occupancy Type:
permit is issued.
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 WITHIN 180 DAYS OF PERMIT ISSUANCE OR
upon the above mentioned property for inspection purposes. (We)agree to save
indemnify and keep harmless the City of Cupertino against liabilities,judgments, 180 DA S FROM LAS ALLED INSPECTION.
costs,and expenses which may accrue against said City in consequence of the A
granting of this permit. Additionally,the applicant understands and will comply h ate:
with all non-point source regulations per the Cupertino Municipal Code,Section Issued by:
9.18.
S;-nature 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 inspection.
the following two reasons: Date:
I,as owner of the property,or my employees with wages as their sole compensation, Signature of Applicant:
will do the work,and the structure is not intended or offered for sale(Sec.7044,
Business&Professions Code) ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
1,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business&Professions Code).
HAZARDOUS MATERIALS DISCLOSURE
I hereby affirm under penalty of perjury one of the following three
I have read the hazardous materials requirements under Chapter 6.95 of the
declarations:
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 Safety Code,S Section 25532(a)should I sto a oth the Cupertino Municial rehand Ithazardous er 9.12 anmaterial the Ith&
performance of the work for which this permit is issued. Additionally,should I use equipment or devices which emit hazardous air
I have and will maintain Worker's Compensation Insurance,as provided for by contaminants as defined by the Bay Area Air Quality Management District I will
Section 3700 of the Labor Code,for the performance of the work for which this maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
permit is issued. Health&Safety C de,Secti s 25505,25533,and 25534.
1 certify that in the performance of the work for which this permit is issued,I shall T
not employ any person in any manner so as to become subject to the Worker's r or iz d agent: Date: r/(J
Compensation laws of California. If,after making this certificate of exemption,I
become subject to the Worker's Compensation provisions of the Labor Code,I must CONSTRUCTION LENDING AGENCY
forthwith comply with such provisions or this permit shall be deemed revoked.
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
the above mentioned property for inspection purposes.(We)agree to save
unify 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- oint sourc =perMunicipal Code,Section9.18. '� Licensed Professional
Signa rate�V
CITY OF CUPERTINO
PERMIT RECEIPT OPERATOR: patg
4 ITEMS OF 4 COPY # : 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 36210001.SJPMPSTN
DATE ISSUED. . . . . . . 04/28/20109
RECEIPT # • • " ' 10040165
REFERENCE ID # • •
SITE ADDRESS 21111 RAINBOW DR SJ PMP STATN
SUBDIVISION • • • . . CUPERTINO
CITY . . . . . . . . . . . .
IMPACT AREA . • • • • • •
OWNER SAN JOSE WATER COMPANY
ADDRESS 110 W TAYLOR ST
CITY/STATE/ZIP SAN JOSE, CA 95110
RECEIVED FROM ALBERT J HAZELBERG
CONTRACTOR LIC # *OWNER*
COMPANY SAN JOSE WATER COMPANY
ADDRESS 110 W TAYLOR ST
CITY/STATE/ZIP SAN JOSE, CA 95110
TELEPHONE . . . . . . . .
UNIT QUANTITY AMOUNT PD-TO-DT THIS REC --NEW-BAL-
FEE ID _ -------
---------- 0 . 00
------------- 0 . 00 1 . 00
---------- 1 . 00
1BCBSC VALUATION 200 .00 0 . 00 0 . 63 0 . 00
200 . 00 0 . 63 0 . 00 0 .00 42 . 00 0 . 00
1BSEISMICO VALUATION 42 . 00 0 .00 42 . 00
1 . 00
lEPERMITFE FLAT RATE 1 .00 42 . 00
-
1TRAVDOC FLAT RATE ---------- - --------
---------- 0 .00 85 .63 0 . 00
85 .63
TOTAL PERMIT :
AMOUNT REFERENCE NUMBER
METHOD OF PAYMENT ----
------------
CREDIT CARD
----------85_63
TOTAL RECEIPT 85 . 63
CITY OF CUPERTINO
CUPCM S Of
GENERAL BUILDING
PERMIT APPLICATION FORM
APN # Date: 18
Building Address: /
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 ElIf es, rovide letter from HOA
Phone#:
Owner's Name: GCS
_Jf) Phone:
Contractor: Fax:
Contractor License#:
Cupertino Business License#: phone:
Contact: Fax:
Residential ❑ Commercial
Job Description: , / � t �Jr—
Re P
G �
Building Permit Info:
Elect Plumb ❑ Mech El
Bldg ❑ Occupancy Type:
Type of Construction(Usage Class):
1-A, 1-B ❑ II/III/V-A ❑ II/III B, IV-HT,V-B�,
Square Footage: 0
Ealua ZOO
Major e: Express ❑ Standard Large❑ .l ❑
[dr_e�enBuilding: Please complete relevant portion of the Green Buildin&he h sheet ndexChecklist & attach it
to the application or if applicable, include in plan se
Points Achieved:
For help, contact Build it Green at www.buflditp-reen.org
Revised 07/14/09
CITY OF CUPERTINO
APPLICATION
Cin OF GENERAL BUILDING
CUPEkT1NO FEE SCHEDULE
Fee Description Fee Permit Type
Quantity/Sf Fee ID Group 1GENRES or
1GENCOM
1STUCOAP
Stucco Applications (up to 400 sf) B
additional stucco application B
1 WINREP Replacement windows/sliding glass
door (ea 8 windows) B
1WINMEWSTR New Window-structural shear
wall/masonry (includes plan ck fee)
. f l EPERMITFEE
Electrical Permit Fee E
I
1 MPERMITFEE Mechanical Permit Fee M
1 PPERMITFEE
Plumbin Permit Fee P
g
1 ELCPLNCK
Stand Alone Electric Pln Ck(hourly) E
1 MECPLNCK 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-stand alone
MIT
L PER
1BCBSC Cal Bldg Standards Commission Fee B ALTYPES
/ Seismic Residential B
1BSEISMICR
1BSEISMICO
Seismic Commercial B
> 1TRAVDOC
Travel &Documentation B
1BUSLIC
Business License B
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