09090084 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10123 N WOLFE RD CONTRACTOR:P.S. SERVICES, INC. PERMIT NO:09070126
0"'NER'S NAME: CUPERTINO SQUARE LLC 2820 E GRETTA LN DATE ISSUED:09/03/2009
t
0,,,NER'S PHONE: 7146831 120 ANAHEIM,CA 92806 PHONE NO:(714)683-1120
LICENSED CONTRACTOR'S DECLARATIONf—
BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class Lic.# y r
MECH RESIDENTIAL J COMMERCIAL
Contractor Date._'�.��_
I hereby affirm that 1 am licensed under the provisions of Chapter 9 JOB DESCRIPTION: INSTL(1)ILUMNTD WALL SIGN TO READ
(commencing with Section 7000)of Division 3 of the Business&Professions "IMAX" WAL
Code and that my license is in full force and effect. SIGN TO BE 3'-6"X 18'-9"(63 SQ FT)
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
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:$4500
1 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:31620096.MALL 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
Date:
granting of this permit. Additionally,the applicant understands and will comply Issued by;,
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18.
RE-ROOFS:
iture Date 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.
❑ OWNER-BUILDER DECLARATION
Signature of Applicant: Date:
1 hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
1,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)
1,as owner of the property,am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE
construct the project(Sec.7044,Business&Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the
California Health&Safety Code,Sections 25505,25533,and 25534. 1 will
1 hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
declarations: Health&Safety Code,Section 25532(a)should 1 store or handle hazardous
I have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally,should 1 use equipment or devices which emit hazardous
Compensation,as provided for by Section 3700 of the Labor Code,for the air contaminants as defined by the Bay Area Air Quality Management District
performance of the work for which this permit is issued. will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sections 25505,25533,and 25534.
Section 3700 of the Labor Code,for the performance of the work for which this �ff C� r„ Date:�x� -
/
Owner or authorized agent: �_
permit is issued.
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 hereby affirm that there is a construction lending agency for the performance of
forthwith comply with such provisions or this permit shall bF deemed revoked. work'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
the above mentioned property for inspection purposes.(We)agree to save ARCHITECT'S DECLARATION
mnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the I understand 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 Licensed Professional
9.18.
Signature Date_
CITY OF CUPERTINO BUILDI'NG PERMIT
BUILDING ADDRESS: 10731 WUNDERLICH DR CONTRACTOR:JAYAN ELLE,LLC PERMIT NO:09090084
OWNER'S NAME: JAYAN ELLE,LLC 10731 WUNDERLICH DR DATE ISSUED:09/11/2009
NER'S PHONE: 4082793400 CUPERTINFO,CA 95014 PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class Lic.#
MECH RESIDENTIAL COMMERCIAL
Contractor Date
I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:DEMO POOL
(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 Sq.Ft Floor Area: Valuation:$2500
performance of the work 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 APN Number:37529002.00 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
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 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 _
granting of this permit. Additionally,the applicant understands and will comply Issued by. Date:
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18.
Signature Date
RE-ROOFS:
All roofs shall be inspected prior to any roofing material being installed.If a roof is
�. OWNER-BUILDER DECLARATION installed without first obtaining an inspection,I agree to remove all new materials for
inspection.
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons: Signature of Applicant: Date:
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) ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
I,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: California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain
I have and will maintain a Certificate of Consent to self-insure for Worker's compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
Compensation,as provided for by Section 3700 of the Labor Code,for the Safety Code,Section 25532(a)should I store or handle hazardous material.
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 defined by the Bay Area Air Quality Management District I will
main air com I' with th upertino Municipal Code,Chapter 9.12 and the
Section 3700 of the Labor Code,for the performance of the work for which this Heal &Saf e, ecti s 25505,25533,and 25534.
permit is issued.
I certify that in the performance of the work for which this permit is issued,1 shall Own or a o ' nt•
not employ any person in any manner so as to become subject to the Worker's ate: _
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 CO TRUCTION LENDING AGENCY
forthwith comply with such provisions or this permit shall be deemed revoked. I here y a mhat there is a construction lending agency for the performance of work's
for which this permit is issued(Sec.3097,Civ C.)
APPLICANT CERTIFICATION Lender's Name
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 Lender's Address
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes.(We)agree to save ARCHITECT'S DECLARATION
unify and keep harmless he Ci of Cupertino against liabilities,judgments,
,and expenses which a e against said City in consequence of the 1 understand my plans shall be used as public records.
granting of this permit.Ad 'io y,the appli ant on erstands and will comply
with all non-point Arce r gu io he uperti o nicipal Code,Section Licensed Professional
9.18. , ) � (�/-�
Signature Date
CITY OF CUPERTINO
3 ITEMS OF 3 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 37529002 . 00
DATE ISSUED. . . . . . . : 09/11/2009
RECEIPT #. . . . . . . . . : BS000008663
REFERENCE ID # . . . : 09090084
SITE ADDRESS . . . . . : 10731 WUNDERLICH DR
SUBDIVISION . . . . . .
CITY . . . . . . . . . . . . . . CUPERTINO
IMPACT AREA . . . . . .
OWNER . . . . . . . . . . . . : JAYAN ELLE, LLC
ADDRESS . . . . . . . . . . : 10731 WUNDERLICH DR
CITY/STATE/ZIP . . . : CUPERTINFO, CA 95014
RECEIVED FROM . . . . : JAYAN ELLE LLC
CONTRACTOR . . . . . . . : LIC ## *OWNER*
COMPANY . . . . . . . . . . : JAYAN ELLE, LLC
ADDRESS . . . . . . . . . . : 10731 WUNDERLICH DR
CITY/STATE/ZIP . . . : CUPERTINFO, CA 95014
TELEPHONE . . . . . . . .
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
1BCBSC VALUATION 2, 500 . 00 1 . 00 0 . 00 1 . 00 0 . 00
1BSEISMICR VALUATION 2, 500. 00 0 . 50 0 . 00 0 . 50 0 . 00
1DEMOPRE SQUARE FEET 0 . 00 490 .00 0 . 00 490 . 00 0 . 00
---------- ---------- ---------- ----------
TOTAL PERMIT 491 .50 0 . 00 491. 50 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CHECK 491 .50 #3386
---------------
TOTAL RECEIPT 491 .50
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
704 DEMO
CITY OF CUPERTINO
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DEMO
CUCITY
tOT1NO PERMIT APPLICATION FORM
APN# � _.�S `�� `� — �j' Date:
Building Address:
Mailing Address (if different from building address):
Owner's Name: Phone:
L�_ �_1(1�_ U(., N L IU$ Z 0-6
Contractor: vw,v e\C � Phone
Fax:
Contractor License #:
Cupertino Business License #:
Contact: Phone:
Fax:
Residential pa""/Sq Footage Commercial ❑ Sq Footage
Job Description:
Valuation:
2-t;-U-0
Project Size: Express�Standard ❑ Large ❑ Major ❑
Please complete relevant portions of the Green Building Checklist & attach it to the application
or if applicable, include on the plan set & the sheet index.
Quantity Fee ID Fee Description Fee Group Permit Type
1DEMORES Demo-Residential B 1SFDWL-DEM
1DEMOPRES Pool Demo Residential B 1SFP00L-DEM
1BCBSC Cal Bldg Standards B ALL PERMIT
Commission Fee TYPES
1BSEISMICRE Seismic Residential B
Revised 01/07/09
OWNER-BUILDER VERIFICATION
1. (Check one) I or my immediate family (parent,spouse or child) will perform:
A. All the work authorized by this permit
B. A portion of the work
C. _ None of the work
If B or C is checked,corn lete 2 or 3 below.
2. A state licensed contractor will be hired to do:
A. — All of the work
B. _ A portion of the work (complete section below)
Contractor Address/City Phone # State License # Type of work to
be performed
3. _ I will utilize unlicensed person(s) other than my immediate family to perform all or
portions of the authorized work. I understand that I may be an employer (see reverse side). A
Certificate of Insurance covering workers' compensation must be on file at the City of
Cupertino Building Department office.
Person/Firm Address/City Phone Number Type of work to be
erformed
...........................................................................................................
I declare under penalty of per" th t e above is true and correct. I have read and understand the
Owner-Builder Information ( vers de).
Property Owner's Signature:
/( Date:
Job Address:
v ti CL f I C Permit#
Any changes to the information provided on this form shall be submitted to the City of Cupertino Build
Department. _ _
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
XPERTINO
Buildin De artment
JOB ADDRESS: j � f'J �r�• PERMIT�D�00�"
l ,7 V cx.�'`r
OWNER'S NAME: ate- L L �— PHONE # Z Z
GENERAL CONTRACTOR: ,u S- r FAX #
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following information:
SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets &Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring: Carpeting
Linoleum/ Wood
Glass / Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
*uu
er/Contra for Signature Date