08080138 CITY OF CUPERTINO
BUILDING DIVISION' PERMIT eCONTRACTORINFORMATION'
eulLpjrbc��o�PsRODRIGUES AVE WILLOW GLEN ELECTRIC INC P�08080138
OWNER'S NAME: PERMIT 0611E DATE
OSBORNE WILILIAM T AND CAROLINE 1085 WARREN AVE 08/19/2008
NE SANITARY NO. CONTROL NO.
ARCHITECrfENGINEER: BUILDING PERMIT INFO
200 AMP PANEL UPGRADE BLDG ELECTPLUMB MECH
0 0 0 0
300 LICENSED CONTRACTOR'S DECLARATION Job Description
1 hereby mRrm Wt I am IRxnsed under provisions of Chapter 9(commaruing
n� wiNSecuon7O)OWD11imm3afale BudrcssaM Prefeu� dc.a/ 1icemcu
in full force and.Bees
?�? Lkensc CLW Lie.g
sI- Dau `%^�Canwnor W
e9 ARCHITECTS DECLARATION
yo( 1 understand my Plans shall he used.,unit.mentis
2yU
yo Licensed Profeasiarml
OWNER-BUILDER DECLARATION
9 1 bereby a?rm Nu I em umap.from dm CanuactM!Lime.law for the
i O following moan.(Salim 7031A.Business and Professions Cade:My my or county
S$ which requires a permit to canuruel.Jur.impmw,demol W,ar repur any structure
prior in its issuance.also requires the applicant for such permit to file a signed muument
�<
that beulicensed pursuant Wthe pmvisimuofthe ComacmrsLu melaw(chapter9 Sq.Ft. Floor Area Valuation
9 (commencing with Section70W)or Divulon 3 of me Business and Profession Code)Of
that be is exempt Nerefmm and the basis far the alleged exemption.Any violation of
Section 70313 by my applicant for a permit ubjeau One applicant to a civil penalty of APN Number Occupancy Type.
not come Nan fiw hundred dollars ISSID).
D 1,as awmr of de property,Or My=play.with wage As Met,sale cempaosstim.
will do the Mark,and the mo etnm is Mt Alumina afaBCRd farmale(gee.7044,B".
and Professions Codw The Gntraemrr LIRM1Y Law does oat apply to m mm of Required Inspections
property who Wllda wimprawa thereon,andwhodonswch workhimmlfar through his
awn employees,provided that such impmvementa am not Intended aroRemd rustle.If.
however,me building or Improwm at is mid within am yea,of completion,me owner-
builder will haw the burden of proving Nat be did not Wild or improv for purpom of
tile.).
1,As menet of the propen,m euluuwly cantmcdng wish 0censed conoacmn m
cauuum
the project(Sec.7044,Busimm and Prafessimu Cade)The Coatrs cmfs U.
teem law does not apply an an awver of property who Wilds m impmw Neman.and
who cammets far much pro cm,with a conuectm(s)Ikeased pursuant As tie Contruwta
Line.law.
D lm"casptundersex. .BBPCfar Nureasm
Owner Data
WORKER'S COMPENSATION DECLARATION
I hereby same under penalty of perjury mon of me following decluatlans:
lave am will malnWn a Ceruf teorCement a aelf-Inmmfor warteYscompen-
ian,as provided fe,by Soudan 3700 of Ne Lahr Cade.for the per...of the
wart for which this perm,is Amount.
D 1 haw and will maintain Worker's Compensation Insurance,As required by Section
3700 of the labor Code,for the performance of the work for which this Permit is Issued. '
My W. a C 'assumn l unities carder and Policy In,um'ber //��
Gmier y](1i✓olymP7,C. Policy No.: `^�5 / -` 1
CERTIFICATE OF EXEMPTION FROM WOME RS'
COMPENSATION INSURANCE
(nds semlm need ant be completed lima Mrmh Is farme hundred dollars($IBM
m last)
1 certify dist in the performance of i m work for which this permit If issued,I Nall not
employ say Mason in any mmmrao as At become subject to me Workess'Compeasadon
Laws of Califomu.Data
Appliwnl
NOTICE TO APPLICANT:If,after making this Certificate of Exemption.you should
became subject of the Worker's Compensation provisions of the labor Code.you moa
O faMwith comply with such providoe of this permit shall be domed revoked.
Z'tiCONSTRUCTION LENDING AGENCY -
(—t 1 berehy aDino Nat them is a eansuuction lending agency of dte performance of
a Ne work far which this permit Is issued(Sec.3097,Civ.C.) '
W� Lender's Name ,
Z)
z landues Address
U O I certify Nu I haw coed this appficaties w sum ma,mm show huromudm is
mrmn I ogres m comply rish all Ary and comfy mdinartces and mute lava rtlNng m
Wilding convection,and thereby aumarien represmutvu of this city to enact upon the
{27 ahem-mentioned property for impaction purposes
(� (We)agree to caw,indemnify,and keep harmltats Use City of Cupcnino against
IA liabilities.judgments,costs and expenses which may In my way acc=against fold City
U z in comegwnw of me ranlinS of this pcmlt. sy
F-t APPLICANT UN A S ND WILL COMPLY WITH ALL NON-POI Issued by: - Date
SOURCE REGU � �VjN ,Iaf(py
Re-roofs
Signature of Appli on sur Disc
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicmt ar future Wilding acmM.Larme whandla hreardoua mauriJ
As defiled by to Cupertino Municipal Code.Chapter 9.12.and he Health and Safety
Coda,Sued.25532(x)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yes Q(Na
WTn the appricam or future Wilding occupant ala equipment or dcvl.which If a roof is installed without first obtaining an inspection,I agree to remove
navardoa air contaminants as deBnsd by she Bay Atha nit Contain,Mangmmt all new materials for inspection.
,man
DYes RNA
I hew mad the Mnardms materialarequifamcnu undo Chapmi95 of ted Califor.
nia Hulsh&Safety Cade.Sections 25505.25533 ao125334.I undenund thmlfNe Wiling
Jan not currently how a tenon llut It u my mmpomihllity w notify de oceupml of me
mgniter�y�.,hi; N toimmanecafacwrmamafOr y Signature of Applicant Date
Own/'erO/l'w/N nFcnt—erg/en�Q All roof coverings to be Class's'or better
CITY OF CUPERTINO
• 3 ITEMS OF 6 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec : Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 35910055 . 00
DATE ISSUED. . . . . . . : 08/19/2008
RECEIPT # . . . . . . . . . : BS000005823
REFERENCE ID .# . . . : 08080138
SITE ADDRESS . . . . . : 20671 RODRIGUES AVE
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : OSBORNE WILLIAM T AND CAROLINE
ADDRESS . . . . . . . . . . : 20671 RODRIGUES AVE
CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-2964
RECEIVED FROM . . . . : WILLOW GLEN ELECTRI
CONTRACTOR . . . . . . . : LONDRE, MARK T LIC # 15897
COMPANY . . . . . . . . . . : WILLOW GLEN ELECTRIC INC
ADDRESS . . . . . . . . . . : 1085 WARREN AVE
CITY/STATE/ZIP . . . : SAN JOSE, CA 95125
TELEPHONE . . . . . . . . : (408) 289-9725
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS RE NEW BAL
--------- ----- ---------- ---------- ---------- ----------
1.13SEISMICR VALUATION 2, 000 . 00 0 . 50 0 . 00 0 . 50 0 . 00
].EPERMITFE FLAT RATE 1 . 00 .40 . 79 0 . 00 40 .79 0 . 00
1TRAVDOC FLAT RATE 1 . 00 40 . 79 0 . 00 40 . 79 0 . 00
----- ----------
----- ------
TOTAL PERMIT8208 0 . 00 82 . 08 0 . 00
CITY OF CUPERTINO
CITY OF
• CUPERTINO GENERAL BUILDING
PERMIT APPLICATION FORM
APN #259/ bDate:
55. 0U -1 -off
Building Address:
;L o[e 7 1 tai o a r'i 5 �e� /a- - � ��(� e r 1i vL;ci
Mailing Address (if different from building address):
Owner's Name: Phone#:
'a'1I1 oSborne, Lj =JF- ZS2-2Z � �
Contractor: Phone: 408-289-97 25
WILLOW GLEN ELECTRIC, INC. Fax: 408-289-1410
Contractor License#: 591918—C10
Cupertino Business License #: 15897
Contact: Mark Londre Phone: 408-640-1840
Fax: q —28 —1410
Residential ❑X Commercial El
Job Description:
Building Permit Info:
Bldg ❑ Elect ® Plumb ❑ Mech ❑
Type of Construction (Usage Class): / Occupancy Type:
1-A, I-B ❑ II/III/V-A ❑ II/III B, IV-HT,V-B ❑
Valuation: Square Footage:
2
Project Size: Express E9---`§tandard ❑ Large ❑ Major ❑
Green Building: Please complete relevant portion of the Green Building/LEED Checklist& attach it
to the application or if applicable, include in plan set & the sheet index.
Points Achieved:
• For help, contact Build it Green at www.builditgreen.org
If Pr 2, i r1--EE
Revised 7/01/08
.Z 2
/ l 7-rc, Io <-
Community Development
10300 Torre Avenue
sf
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408) 777-3333
�UPERTINO
Building Department
JOB ADDRESS � PERMIT# 62Gce U/z G
OWNER'S NAME: 5 PHONE #
ice JQ
GENERAL CONTRACTOR 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 C l C
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
TileNvT� n
• Oi — 7
er/Contractor Signature Date