07100031 CITY OF CUPERTINO {`'� �±
BUiLDIIVG DIVISION PERMIT ���� �^��� �����lIQ� ; '
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PERMIT NO.
BUILD N AD RESS:
�51�0 CALIFORNIA OAK WAY BOTHWEL]� CONSTRUCTION CORP. 07100031 �
PERMIT LSSUE DATE
OWNER'S NAME:
PG&E 1590 INI �USTRIAL AVE 10 03 2007
SANiTARY NO. CONTRO(. NO.
NE:
(408) 2:�8-8049 •
BUfI.DING PERMiTINFO
ARC HI'IECT/ENGINEER:
HLDG ELECT PLUMB MECH
� 0 0 0
i p Q LICENSED CON7RACTOR'S DECLARATION JOb DeSCi1pt10II
; v F I hcreby aCGrm that I am licensed undcr provisions oC Chaptcr 9(rnmmcncing
; Z � witA Scction 7000) of Division 3 of ihc Busincss and Profcssions Code, and my licenac is TEMPORA] ZY POWER C ELL S I TE ANTENNA I NSTAL LAT I ON ON
?� y in fu0 force and cCte ys a y�5 ( E� PG&. � TOWER .
, v� z Licen� ass Lic. x
: F , o Da�c � Contractor Q'�' �-+R. ( r
�� ARCHITECI'S DECLARATION �h y�1` � ; p y�
i� a 1 undcrsiand my plans shalt bc uscd as pu6lic recards
)yV
' �. F' Licensed Pni(essional
' � < OWNER-BUII.DER DECI.ARATION
°} J 1 hcrchy alTirm Ihat 1 am excmpt Crum ihc Contraaors Liccnsc Law far thc
� q o following rcazon. (Sccuon 71)31.5, Busincss and Profcuions Ca1c: Any city or county
<,°, � which requircs a pc�mit to rnnswc4 e��. impmve. dcmalish. or repair any swcm�c
� Z} prior to ils issuancc, alsu rcquires Ihc applicant for such permit to filc a signcd stalcmcni ��, Ft. Floor Area Valuation
�_ � that hc is IiccnxJ pursuanl to thc provisions of thc Contractor's Licensc taw (Chap�cr 9 •�q
� t- �(commencing wi�h Section 7000) of Division 3 of �he Business and Profeuians Code) or � 12 � �
,, �.. that he is ezempt thercfrom and the basis for the alleged eumptioa Any violuion o(
Secrion 7031.5 by a�ry applicant for a permit subjccts �he applicant to a civil penalty af Number Oceupancy Type
not more than five 6undred dollars (5500). 3'4 2 6 3 � � ���
❑ I, u owner o[ tl�e propecry, or my employeu with wages u their sole compensation,
wilidothcwork.andihestcucta�eisnotinundedorolleredforsale(SecJ Required Inspections
and P�ofessions Cadc: The Conuutors License Law does not apply io an owrrcr of
property who builds or improves theccon, and who daes such work himselCor Uuough his
own employccs, provided that such improvemen�s are not intended or otTeied for sala [C,
however. We building or improvement is sold within one yesr oC completion. �he owner-
builder will have the burden oC proving tha� hc did not buiW or improvc Cor Qurpou of
sakJ.
❑ l, u awner of the propeny, am exclusively contracting wiW licensed rnnuutors a
wnstnxt U�e projea (Sec. 7044. Businas and Professions Cade:) TAe Cootracwr's Li-
ccnse Law docs not apply io an owncr of propeny who builds or improvrs Ihemon. uid ,
who convacts Cor such projects with a comractar(s) licensed pursuan[ to Ihe Conuacror's
License L.aw.
❑! am ezcmpt under Sec. , B dc P C tor �his icuon
Owner Date _... _:
WORKER'S COMPENSATION DECLARATION
I hercby �rm under penalty of pe�jury one o[ �he following declaratiuos:
❑ I hsve and will main�ain a CeniGcatc of Coasent to self-inw¢ for Worlmis Compen-
sation, u provided for 6y Section 3700 oC the Iabor Code. for �he performance af Ihe
work for which Ihis permit is issued.
❑ I have and will maintain Workcr's Compensadon Insunna, ac tcqui¢d by Scctian ,
3700 oC the Labor Code, Cw the performance of �he work for which ihis pem�it is issued.
My Worke�s Compensauon Insurance camer and Poliry number are: �
� ��'w�F.Q, �J�n � Poliry No.: I� 6 O� � l
CERTIFICATE OF EXEMPT70N FROM WORKERS'
COMPENSATION INSURANCE
(This section necd not bc comple�d i( the pc[mit is for onc hunMed dollars (S I00)
or Icss.)
1 cenify thai in �hc pertormancc of thc work (or which �his permit is issucd. I shall not
employ any person in any mannc� so as to bccomc wbject to the Worrccf Compensuio�
Laws of Califomia. Datc
Applicant
NOTICE TO APPLICANT: If, af�cr making �his Ccrti[icate of ExcmpGon, you shautJ
become subjcct a thc Worker's Compcnsation provisions of �hc La6or Codc, you must
� z forthwiW comply with such provisions a this permit sha0 6c dccmcd rewtcd.
z O CONSTRUCCION LENDING AGENCY
(.�-� � I hcre6y afGrm ihat thcre is a constcuction lcnding agcney (or �hc perfortnancc uf .
SY, � Uic vwrk Cor which this permit is issucd (Scc. 3097. Civ. C.)
(7a Q Lcndcr's Namc
a z Lender's Address
U � 1 ccrtify ihal I havc rcad this applicatio� and su�e ihat thc abovc infom�atiun is
w �'-' cortcc� l agra to comply with aIl city and county onlinances and sute laws rclaiing to
.� U building conswction, and hcreby authori�e reprcscnuiivcs of ihis city to cntcr u�n thc
� a above-mrn�iuncd properry for inspection purposet.
(Wc) agree to save, indcmni(y and kccp harmless the City o( Cupcnino against
�� IiabiliUes,judgmcnls, costs and expenscs which may in any way acc[uc againstsaid City •
U z in consequence of thc granting of this permi� Date �� �J '��
�+ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POIM Issued by:
SOURCE REG ONS.
�� � 10, 3 /� -� Re-roofs ��
Signaturc of I� dConuactor T of R oof
HAZARDOUS MA'CERIALS D[SCLOSURE YP
Will ihe applicant or futurc building occupant store or handle ha•rardous matcriat
u dcfincd by 1he Cupertino Municipal Codc. Chap�cr 9.12, md t!� Hcalth and Safcty
c� Scction 25532(a)? All roofs �hall be inspected prior to any roofing material being installed.
❑ Ycs �J No ,
Will �hc applicant or future building accupant usc eyuipmcnt or dcviccs which
If a roof i; installed without first obtaining an inspection, I agree to remove
cmit harardous air contaminan�s az dcfincd by the Bay Area Air Quality Mana6cmcnt all new m aterials for inspecrion.
Disirici?
❑ Ycs � Nu
I havc rcad ihe ha�ardcws ma�erials �cquirements undcr Chap�cr 6.45 oC ihc Califor-
nia Hcalih & Safcty Cadc, Sccrions 25505.25533 and 25534.1 un�rstand �hat iC�he huilding
dacs na� curtcnlly havc a tcnan4 �� �� u my responsibiliry W noufy �hc accupant nf Ihe
rc' mc which�st bc met prior W issuancc oCa Ccrtificate of Occupan Signature of Applicant Date
[�� J 1 �I 3 � � All roof coverings to be Class "B" or better
Owncr or autho zc agcn� Datc
CITY OF CUPERTINO
2 ITEMS OF 2 PERMIT RECEIPT OPERATOR: suew
COPY # : 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN ........: 34263001.00
DATE ISSUED.......: 10/03/2007
RECEIPT #.-.••••••: BS000002872
REFERENCE ID # ...: 07100031
SITE ADDRESS .....: 10110 CALIFORNIA OAK WAY
SUBDIVISION .......
CITY .............: CUPERTINO
IMPACT AREA .......
OWNER ............: PG&E
ADDRESS ..........: 10110 CALIFORNIA OAK WAY
CITY/STATE/ZIP ...: CUFERTINO, CA 95014
RECEIVED FROM ....: DUSTE RIDINGS
CONTRACTOR .......: GLENN BOTHWELL LIC # 29478
COMPANY ..........: BOTHWELL CONSTRUCTION CORP.
ADDRESS ..........: 1590 INDUSTRIAL AVE
CITY/STATE/ZIP ...: SAN JOSE, CA 95112
TELEPHONE ........: (408) 298-8049
FEE ID UNIT QUANTITY PMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
BTEMP FLAT RATE 1.00 62.10 0.00 62.10 0.00
EPERMITFEE FLAT RATE 1.00 40.79 0.00 40.79 0.00
---------- ---------- ---------- ----------
TOTAL PERMIT : 102.89 0.00 102.89 0.00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CREDIT CARD 102.89 MC
---------------
TOTAL RECEIPT : 102.89
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
103 UFER 304 ROUGH ELECTRICAL
CITY OF C'UPERTINO
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CUPER�TIN� PERMIT APPL�[CATION FORNI p�/�
APN # Date:
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Building Address:
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Owner's Naine: Phone #:
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' C:ontractor: Phone: Lice�lse �: � �
�o�}.�e,l� CQnS��v�i-;o �oc `�OSs , aq�S��oy �Sa��S
Contact: Phone: Cupertino Business License #:
5`0�� T"�.o 5Q ya�--�! ��00�3 � T�� �
Building Permit In o:
Elect C�
Job Description:
�..z�� S; t� a,-.�em ro� "� r5� 1��' a o o n 2�C ;s�;,n P y C, ie�wQ('
Residential �-� Commercial �J
Cost of Proj ect:
�� a�o
Qty. if
Ap lic le Fee ID Fee Descri tion Fee Grou
BTEMP Te n orary Power ELECTRICAL
EPERMITFEE Elf:ct. Permit Issuance ELECTRICAL
BUSLIC Business License BUILDING
Community Development
' 10300 Torre Avenue
�� `� Cupertino CA 95014
Telephone (408) 777-3228
CITY OF Fax (408) 777-3333
':UPEf�TINO
Buildi:n De artment
JOB ADDRESS: PERMIT # �
� 0>> o c �,� =�� ��'� �. 0\Z d�/�l-��J�
OWNER'S NAME: $� � } t PHONE #
GENERAL CONTRACTOR �,o�h .�,1 � Cd» s'�� ���'= � F� #
I am not using any subcontractors:
Si�;nature Date
Please check a licable subcontractors and com �lete the followin information:
SUBCONTRACTOR BUSIrfESS NAME BUSINESS LICENSE #
Cabinets & Millwork
Cement Finishing
� IIectrical � a �,., 5 0 ,� } S
F�ccavation
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
� � ° JO 3 �
- - er�Contractor Signature Date