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09110148 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10101 N WOLFE RD CONTRACTOR:TBD-TO BE DETERMINED PERMIT NO:09110148 OWNER'S NAME: SEARS ROEBUCK AND CO DATE ISSUED: 11/24/2009 PHONE NO: ER'S PHONE: 4088889397 ❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG I— ELECT T_ PLUMB f License Class Lic.# MECH T_ RESIDENTIAL COMMERCIAL Contractor Date JOB DESCRIPTION:GAS GENERATOR I hereby affirm that I am licensed under the provisions of Chapter 9 **SEE NOTES********* (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: 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. 1 have and will maintain Worker's Compensation Insurance,as provided for by Sy,Ft Floor Area: Valuation:$500 Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. APN Number:31620080.00 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 WITHIN 180 DAYS OF PERMIT ISSUANCE OR indemnify and keep harmless the City of Cupertino against liabilities,judgments, 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,Sectione 9.18. Issued by: � Date: Signature Date 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. 1,as owner of the property,or my employees with wages as their sole compensation, Date: will do the work,and the structure is not intended or offered for sale(Sec.7044, Signature of Applicant: 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 and will maintain a Certificate of Consent to self-insure for Worker's 1 have read the hazardous materials requirements under Chapter 6.95 o the Health&Safety Code,Sections 25505,25533,and 25534. I will maintain Compensation,as provided for by Section 3700 of the Labor Code,for the California performance of the work for which this permit is issued. compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health& 1 have and will maintain Worker's Compensation Insurance,as provided for by Safety Code,Section 25532(a)should 1 store or handle hazardous material. Additionally,should 1 use equipment or devices which emit hazardous air Section 3700 of the Labor Code,for the performance of the work for which this contaminants 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 1 certify that in the performance of the work for which this permit is issued,I shall Health&Safety Code,Sections 25505,2553UndI5,514.,not employ any person in any manner so as to become subject to the Worker's �ent: Compensation laws of California. If,after making this certificate of exemption,I er or a�tho ' g Date: become subject to the Worker's Compensation provisions of the Labor Code,I must 1't 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,thekapplicant understands and will comply with all non point source re lation r e Cupertino MunicipJCode, tion I understand my plans shall be used as public records. 9.18. -,o'" � , � Licensed Professional "�--' /// Date I Signature CITY OF CUPERTINO 4 ITEMS OF 4 PERMIT RECEIPT OPERATOR: patg COPY # : 1 Sec: Twp: Rng: Sub: Blk: Lot: APN 31620080 .00 DATE ISSUED. . . . . . . : 11/24/2009 RECEIPT #. . . . . . . . . BS000009282 REFERENCE ID # 09110148 SITE ADDRESS 10101 N WOLFE RD SUBDIVISION . . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . OWNER SEARS ROEBUCK AND CO ADDRESS . . . . . . . . . . CITY/STATE/ZIP RECEIVED FROM . . . . BBD-DOOIgEIDE LINE DETERMINED LIC # 00096 CONTRACTOR . . . . . . . COMPANY TBD - TO BE DETERMINED ADDRESS . . . . . . . . . . CITY/STATE/ZIP TELEPHONE . . . . . . . . FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC --NEW-BAL- ---------- ------------- ---------- ---------- ---------- ----- 1BCBSC VALUATION 500 . 00 1 . 00 0 .00 1. 00 0 . 0 1BSEISMICR VALUATION 500 . 00 0 .50 0 .00 0 . 50 0 .00 lERT<200 UNITS 1. 00 42 . 00 0 .00 42. 00 0 .00 1. 00 42 . 00 0 .00 42 . 00 ------0_00 1TRAVDOC FLAT RATE ---------- ---------- ---------- TOTAL PERMIT : 85 .50 0.00 85 . 50 0 . 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ------------ -- --------------- --- CREDIT CARD 85 .50 VISA --------------- TOTAL RECEIPT 85 .50 ID DESCRIPTION VOICE ID DESCRIPTION VOICE ---------------------------- -------- ---------------------- 402 TEMPORARY POWER OWNER-BUILDER VERIFICATION 1. (Check one) I or my immediate family (parent,spouse or child) will perform: A. 4 All the work authorized by this permit B. _ A portion of the work C. None of the work If B or C is checked,complete 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 -performed ............................................................................................................................................................................ I declare under penalty of perjury that the above is true and correct. I have read and understand the Owner-Builder Information (reverse si01 ,1 ... `� . Property Owner's Signature: Date: i Job Address: I Ol w 1 V ��-� `� '-�--� Permit# Any changes to the information provided on this form shall be submitted to the City of Cupertino Build Department. > /I o1 � CITY OF CUPERTINO TEMP POWER CUPE�TINO PERMIT APPLICATION FORM APN # � go Date: Building Address: Owner's Name: Phone Contractor: Phone #: -' j f4 -- 1`-p Fax #: Contact: Phone #: Contractor License #: Cupertino Business License #: Job Description: C-A!�, C-- Residential Commercial Valuation (cost of project): �—00 Type of Construction N/ Quantity Fee ID Fee Description Fee Group Permit Type IERT>1K Res. Temp Power>IK E 1REAP14 Amps IERT<200 Res. Temp.Power<200 E Am s 1 ERT2001 K Res. Temp Power 200-1 K E Amps 1 EPERMITFE 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 & Documentation B Fee Revised 01/07/09