10030067 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10650 SANTA LUCIA RD CONTRACTOR:TBD-TO BE DETERMINED PERMIT NO: 10030067
OWNER'S NAME: JOSHUA&SHABNAM RICHARDSON DATE ISSUED:03/11/2010
NER'S PHONE: 4082054264 PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATIONr—
BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class Lic.#
MECH r— RESIDENTIAL F COMMERCIAL
Contractor Date
I hereby affirm that I am licensed under the p p provisions of Chapter 9 JOB DESCRIPTION:TEMPORARY POWER AT PERMANENT LOCATION(commencing with Section 7000)of Division 3 of the Business&Professions **SEE NOTES**
Code and that my license is in full force and effect. J //–�
I hereby affirm under penalty of perjury one of the following two declarations:
1 have and will maintain a certificate of consent to self-insure for Worker's r cA
Compensation,as provided for by Section 3700 of the Labor Code,for the ` '
performance of the work for which this permit is issued. S��
I have and will maintain Worker's Compensation Insurance,as provided for by Sq.Ft Floor Area: Valuation:$1000
Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued.
APN Number:34216035.00 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 regulations per the Cupertino Municipal Code,Section
9.18. Issued by: � G Date:
Signature Date
l 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 Owner or author' a nt /�
become subject to the Worker's Compensation provisions of the Labor Code,I mush Date: 0
forthwith comply with such provisions or this permit shall be deemed revoked.
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
nify 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
with all non-point source regulations per the Cupertino Municipal Code,Section I understand my plans shall be used as public records.
9.18.
J Licensed Professional
Signature Date
CITY OF CUPERTINO
5 ITEMS OF 5 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN 34216035 . 00
DATE ISSUED. . . . . . . : 03/11/2010
RECEIPT #. . . . . . . . . BS000009916
REFERENCE ID # 10030067
SITE ADDRESS 10650 SANTA LUCIA RD
SUBDIVISION . . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . .
OWNER JOSHUA & SHABNAM RICHARDSON
ADDRESS 10650 SANTA LUCIA RD
CITY/STATE/ZIP . . . : CUPERTINO CA, CA 95014-3938
RECEIVED FROM SHABNAM RICHARDSON
CONTRACTOR TBD - TO BE DETERMINED LIC # 00096
COMPANY TBD - TO BE DETERMINED
ADDRESS . . . . . . . . . .
CITY/STATE/ZIP . . . :
TELEPHONE . . . . . . . . :
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- -------------
---------- ---------- ----------
1BCBSC VALUATION 1, 000 . 00 1. 00 0 . 00 1 . 00 0 . 00
1BSEISMICR VALUATION 1, 000 .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 MC
---------------
TOTAL RECEIPT 127.50
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
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402 TEMPORARY POWER
CITY OF CUPERTINO
TEMP POWER
CUPEI�TINO PERMIT APPLICATION FORM
APN # Date:
Building Address:
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Owner' Name: T o S l Phone #:
2 6 5 - q Z-la
Contractor: Phone #: 0 7/S-- 7&
^ ra Fax #:
Contact: ? Phone #:
Contractor License #:
Cupertino Business License#:
Job Description: >
ryk
Residential Commercial Ej
Valuation(cost of project): Type of Construction: N/A
Quantity Fee ID Fee Description Fee Group Permit Type
IERT>1K Res. Temp Power>1K E 1REAP14
Amps
IERT<200 Res. Temp.Power<200 E
Amps
1 ERT2001 K Res. Temp Power 200-1 K E
Amps
1 EPERMITFE Electric Permit Issuance E
1 ELCPLNCK Electric Plan Check E
/i 1BCBSC Cal Bldg Standards B ALL PERMIT
/ Commission Fee TYPES
1BSEISMICR Seismic Residential B
/ 1TRAVDOC Travel & Documentation B
Fee
Revised 01/07/09