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09090023I CITY OF CUPERTINO BUILDING PERMIT I BUILDING ADDRE-IS: 10120 N DE ANZA BLVD " NER'S NAME: ST. JOSEPH CHURCH OWNER'S PHONE: 1082526441 CI LICENSED CONTRACTOR'S DECLARATION License Class Lic. # Contractor 1 hereby affirm that 1 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 wort: for which this permit is issued. 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 perrrut is issued. APPLICANT CERTIFICATION I ,,ert•fy 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 indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs, and expenses whi ch 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 9.18. latare Date OWNER -BUILDER DECLARATION 1 hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: 1, as owner of the property, or my employees with wages as their sole compensation, will do the work, and the structure is net intended or offered for sale (Sec.7044, Business & Professions Code) 1, as owner of the property, am exclusively contracting with licensed contractors to construct the project (S;c.7044, Business & Professions Code). 1 hereby affirm under penalty of perjury one of the following three declarations: 1 have and will maintair. 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. 1 have and will maintain Worker's Compensation Insurance_ as provided for by Section 3700 of the Labor Code, for the performance of the :vork for which this permit is issued. 1 certify that in the peribrmance of the work for which this permit is issued, I shall net employ any person i., any manner so as to become subject to the Worker's Comncnsation laws of California. If, after making this certiticate of exemption, I become subject to the Worker's Compensation provisions of the Labor Cede, 1 must forthwith comply with sack previsions or this permit shall be deemed revoked. .APPLICANT CERTIFICATION I certify that I have reau this application and state that the above information is correct. I agree to comply with all city and county ordinances and state laws relating t- ouilding construction, and hereby authorize representatives of this city to enter the above mentioned property for inspection purposes. (We) agree to save .,comfy and keep harmless the City of Cupertino against liabilities, judgments, 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 9.18. Signatture__ ��-� uJ��' DateQ_ -L C CONTRACTOR: ANTHONY PERMIT NO: 09090023 HODDER CONSTRUCTION 7504 BOLLINGER RD DATE ISSUED: 09/04/2009 CUPERTINO, CA 95014 PHONE NO: (408) 2574317 BUILDING PERMIT INFO: BLDG ELECT PLUMB f— I MECH RESIDENTIAL COMMERCIAL JOB DESCRIPTION: TEMP POWER FOR CARNIVAL Sq. Ft Floor Area: I Valuation: $3000 APN Number: 11626093.00 1 Occupancy Type: PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTION. Issued b!y: Date: 3"dip r� RE -ROOFS: 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 inspection. Signature of Appl Date. ALL ROOF COVERINGS TO BE CLASS "A" OR BET"I'ER HAZARDOUS MATERIALS DISCLOSURE I have read the hazardous materials requirements under Chapter 6.95 of the California Health & Safety Code, Sections 25505, 25533, and 25534. 1 will maintain complianee with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Section 25532(a) should 1 store or handle hazardous material. Additionally, should I use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management District 1 will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Sections 25505, 25533, and 25534. Owner or authorized agent: __Z Date: CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of work's for which this permit is issued (Sec. 3097, Civ C.) Lender's Name Lender's Address ARCHITECT'S DECLARATION I understand my plans shall be used as public records. Licensed Professional 4 ITEMS OF 4 CITY OF CUPERTINO PERMIT RECEIPT Sec: Twp: Rng: Sub: Blk: Lot: APN ........: 11626093.00 DATE ISSUED.......: 09/04/2009 RECEIPT #.........: BS000008608 REFERENCE ID # ...: 09090023 SITE ADDRESS .....: 10120 N DE ANZA BLVD SUBDIVISION ...... CITY .............. CUPERTINO IMPACT AREA ...... OWNER ............: ST. JOSEPH CHURCH ADDRESS ..........: 10120 N DE ANZA BLVD CITY/STATE/ZIP ...: CUPERTINO, CA 95014 OPERATOR: SylviaM COPY # : 1 RECEIVED FROM ....: ERIN EDEM CONTRACTOR .......: ANTHONY HODDER LIC # 28979 COMPANY ..........: ANTHONY HODDER CONSTRUCTION ADDRESS ..........: 7504 BOLLINGER RD CITY/STATE/ZIP ...: CUPERTINO, CA 95014 TELEPHONE ........: (408) 257-4317 FEE ID UNIT QUANTITY AMOUNT PD -TO -DT THIS REC NEW BAL ---------- ---------- 1BCBSC ------------- VALUATION ---------- 3,000.00 ---------- 1.00 ---------- 0.00 ---------- 1.00 0.00 1BSEISMICR VALUATION 3,000.00 0.50 0.00 0.50 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 ---------- 85.50 ---------- 0.00 ---------- 85.50 ---------- 0.00 METHOD OF PAYMENT ----------------- CREDIT CARD TOTAL RECEIPT : AMOUNT --------------- 85.50 --------------- 85.50 REFERENCE NUMBER -------------------- visa VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 402 TEMPORARY POWER I�kf�N6+ NAU-- ® ®?.., 0 DE ANO ice. REQ J, tat PA Tn Tc�nK.is Poen Poly y s s s�n� wns,n p I f Uib ROVED THE CITY �p p C��ES l�lr�c� NA OF t. DATE ( -- ---- SIGNE __— -- ificabons MUST { This set of plans and spec it's be kept on the lob at all times and t' unlawful to make any changes or alterations on same without written permission from �. rtment, City of Cu mo. the Building lan and spec; ;cations I. The stamping o this u SHALL NOT be held to permit or to be an approval of the violation of any provi of any City Ordinance or State c�1 OF CUPE;KT��IQ 10100 n/V27,,4 C U PER—PNOe PA up S' Gd (' � 1.x•.9 <:�-� ryl UPPGf CourT Lower Cour+ YArb � Yiard r—r1,: K��chen CST M! m 5 Jeep` I � Ceo'r orrxi- 1 1 w LI L. - ^ Q l b CnrtRPffk n o U'J ' J rV Tup W"Y Affi L i N estr; 2AL CF ork {AL.L. OF t�L.&jcraVA90 Pottrs. UTA41n LmNity Ams x Dn.fs4er Rmg4mol4r U6AA-4 �C S L 7 8 9 io I 1 3 �?"°• ART -5_ 6,)e,q 5s ArEA M!: V. R qd rz A 99#1 nix ORrm%w 54«FF Lall"A pPa��S�Pr. Wa1Yg14% �jh. b GAme 13 i -hs »r �4 I r Reverase Bm}. h 7» fit -•� ! !oro E , ._ ioa 10 �creer,na r,' _s Tv I3 E t,�l/NED Pay W � z�ia6G yO6G a KTTYPE- IEn. of ower Box i) �� Sclf Ca j'AiNe� L;�ht Tower 4 Ins+cJ] ��' �� it •. y CITY OF CITY OF CUPERTINO TEMP POWER C U P E RT I N O PERMIT APPLICATION FORM 0q09 O� APN # Date: 1 I (..v 2c.o 0 C? 3.0 67� Building Address: �p 1 01 N , Fj l�Cn O Phone #: Owner's Nie: 1 _ (� �� L A(0 c c I J o 5e �l. CTT J Contractor: �4 n j �-' Phone #: 40% r�'0L,,. G91 7 �l Fax #: Contact: S� y\,p o 1'r i e f; Phone #: (,, 0_ C Zq -LJ 00 0 V) Contractor License #: qq Cupertino Business License #: Job Description: -T Si7• e 1�, d"F e,rtl ,nv C.al ren I VQ� 1 T.1'Yl O W C' (' Jo+ P a 3 L4P, Commercial r Residential bL Lir Valuation (cost of project): Type of Constructio N A 3 000 .o a Quantity Fee ID Fee Description Fee Group Permit Type IERT<200 Res. Temp Power <200 E 1REAP14 Amps IERT2001K Res. Temp Power 200-1K E Amps IEPERMITFE Electric Permit Issuance 1BCBSC Cal Bldg Standards B ALL PERMIT Commission Fee TYPES 1BSEISMICR Seismic Residential B 1TRAVDOC Travel & Documentation B Fee Revised 06/12/09