11110165 1 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 22755 SAN JUAN RD CONTRACTOR:WJB-CANYON LLC PERMIT NO: 11110165
OWNER'S NAME: WJB-CANYON LLC 2175 DE LA CRUZ BLVD DATE ISSUED: 11292011
ER'S PHONE: 4082349061 SANTA CLARA,CA 95050 PHONE NO:
Mr LICENSED CONTRACTOR'S DECLARATION r C I J
BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class Lic.N r I—I r
MECH RESIDENTIAL COMMERCIAL
Contractor Date
I hereby affirm that 1 am licensed under the provisions of Chapter 9 JOB DESCRIPTION:TEMP POWER POLE
(commencing with Section 7000)of Division 3 of the Business&Professions
Code and that my license Is in full force and effect.
1 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 work for which this permit is issued. Sq.Ft Floor Area: Valuation:S175
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
permit is issued. APN Number:34217068.00 Occupancy Type:
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is
correct.1 agree to comply with all city and county ordinances and state laws relating PERMIT EXPIRES IF WORK IS NOT STARTED
to building construction,and hereby authorize representatives of this city to enter
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, 1g0 DAYS FROM LAST CALLED INSPECTION.
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 Issued by: Date:
9.18.
Signature Date
RE-ROOFS:
OWNER-BUILDER DECLARATION All roofs shall be inspected prior to any roofing material berg installed.If a roof is
installed without first obtaining an inspection,I agree to remove all new materials for
hereby affirm that I am exempt from the Contractor's License Law for one of inspection.
the following two reasons:
I,as owner of the property,or my employees with wages as their sole compensation, Signature of Applicant: Date:
will do the work,and the structure is not intended or offered for sale(Sec.7044,
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: 1 have read the hazardous materials requirements under Chapter 6.95 of the
I have and will maintain a Certificate of Consent to self-insure for Worker's California Health&Safety Code,Sections 25505,25533,and 25534. 1 will maintain
Compensation,as provided for by Section 3700 of the Labor Code,for the compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
performance of the work for which this permit is issued. Safety Code,Section 25532(x)should I stare or handle hazardous material.
I have and will maintain Worker's Compensation Insurance,as provided for by Additionally,should I 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. mai11144tampusimermAh,the Cupertino Municipal Code,Chapter 9.12 and the
I certify that in the performance of the work for which this permit is issued,I shall Hee ections -,25533,and 25534.
not employ any person in any manner so as to become subject to the Worker's Ow r oca v
Compensation laws of California. If,after making this certificate of exemption,I Date:
become subject to the Worker's Compensation provisions of the Labor Code,I must
forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending agency for the performance of work's
APPLICANT CERTIFICATION for which this permit is issued(Sec.3097,Civ C.)
I certify that I have read this application and state that the above information is Lender's Name
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 Lender's Address
upon the above mentioned property for inspection purposes.(We)agree to save
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
iftand expenses which may accrue against said City in consequence of the ARCHITECT'S DECLARATION
Ivtg of this pe 'otwl lheepplicrol and, and will comply I understand my plans shall be used as public records.
a ll no in r MH ego Itr'Municipal Code,Section
Licensed Professional
Signator Date ��-U
• CITY OF CUPERTINO
6 ITEMS OF 6 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 34217068. 00
DATE ISSUED. . . . . . . : 11/29/2011
RECEIPT #. . . . . . . . . : BS000015429
REFERENCE ID # . . . : 11110165
SITE ADDRESS . . . . . : 22755 SAN JUAN RD
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : WJB-CANYON LLC
ADDRESS . . . . . . . . . . : 2175 DE LA CRUZ BLVD
CITY/STATE/ZIP . . . : SANTA CLARA, CA 95050
RECEIVED FROM . . . . : BARRE BARNES
CONTRACTOR . . . . . . . : LIC # *OWNER*
COMPANY . . . . . . . . . . : WJB-CANYON LLC
ADDRESS . . . . . . . . . . : 2175 DE LA CRUZ BLVD
CITY/STATE/ZIP . . . : SANTA CLARA, CA 95050
TELEPHONE . . . . . . . . :
• FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
-ADMIN HOURS 1 .00 41. 00 0.00 41.00 0.00
1BCBSC VALUATION 175 .00 1. 00 0 .00 1.00 0 . 00
1BSEISMICR VALUATION 175 . 00 0. 50 0.00 0.50 0.00
1EPERMITFE FLAT RATE 1. 00 44 . 00 0. 00 44 .00 0.00
IERT<200 UNITS 1. 00 44 . 00 0 . 00 44 .00 0.00
1TRAVDOC FLAT RATE 1. 00 44 .00 0. 00 44 .00 0.00
---------- ---------- ---------- ----------
TOTAL PERMIT 174 . 50 0. 00 174 .50 0.00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CHECK 174 . 50 #276
---------------
TOTAL RECEIPT 174 . 50
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
402 TEMPORARY POWER
•
GENERAL PERMIT APPLICATION I
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION l
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255
•CUPERTINO (408)777-3228• FAX(408)777-3333• buildina(&.cuoertino.ora M ' S
PLUMBING MECHANICAL &ECTRICAL MISCELLANEOUS
PROJECT ADDRESS 7s5 �(�_ APNa
OWNERNAAffi PHONE
STAE7STADDAE53 .� / L ,7�n CRYO STATE,ZpiPv ZyJ� �/NA ' FA7C -OL7 /%y�r
CONTACT NAME PHONE/C/O ��✓(/ � /�✓[�BYMAII. �& 6QN�'•y' C/� .GE-[ate
STREETADDRES9 CITY,SLATE, ZIP FAX ✓/�Gl^�
❑ OWNER OWNER-BUDDER OWNER AGFNr ❑ cuM crOR ❑CONTRACTOR AGENT ❑ AscarraCr ❑EJIr-WHET ❑ DEVELOPER ❑TENANT
CONTRACTOR NAME LICENSENUMBER LICENSE TYPE BUS.LIC0
COMPANY NAME E-MAIL FAX
STRMA13DRESS CITY,STATE,Z@ PHONE
ARCRITECTJENOINEERNAME LICENSE NUMBER BUS.LIC a
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIF PHONE
Ad Ilk I I
SE OF SFD mOUPLIX ❑ MULTI-FAMILY PROJECrINWILDWM ❑ YES PROIECTIN ❑YES DTHEBLDGAN ❑ YES
BUDDING; gNbMaAL URBAN INTERFACE AREA [3 NO FLOOD ZONE ❑NO MCHLER HOME? ❑NO
DESCRIPTION OF WORK
Vq
TOTAL VALUATION: RECEIVED BY:
By my signature below,I certify m e the authoriad agent to act oD the property owner's behalf. I have read this
application and the iaformad ave pro==d is 0Tec of Work and verify it is eccumm. I ague to comply withIll applicable local
ordinances and smm laws g m an esenm of Cupertino to enter the above-' Gfied pryperry r' cdao pu�Jeaes.
Signal=ofAppErsnUAgrn Dam:
SUPPLEMENT QLIIRED OFFICE USE ONLY
W ❑ oYER-THF.CouNTER
6
❑ K"RESS
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m ❑ STANDARD
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❑ LARCE
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❑ MAJOR
MEPMucApp_2011.doc revised 06/21111
CITY OF CUPERTINO
FEE ESTIMATOR—BUILDING DIVISION
ADDRESS: 22755 SAN JUAN DATE: REVIEWED BY:
APN: BP#: `VALUATION: $175
*PERMIT TYPE: Electrical Permit PLAN CHECK TYPE: Alteration/Addition/ Repair
PRIMARY SFD or Duplex PENTAMATION 1 REAP14
USE: PERMIT TYPE:
WORK TEMP POWER POLE
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Temporary Power 1ERT<200 100 Amps $44
TOTALS: 1 $44.00
111,1jrChodc Plumb. Plan Cheok 171 Elec.Plan Check 0.0 1 hrs $0.00
:t-leeh. Pen0i Fee: Plumh Permit Fee: Elec.Permit Fee: IEPERMIT
i
. Ulmer.11,vae!rasp. OtGn f'liunl>Lr,:p. Other Elec. Insp. 0.0 hrs $44.00
Hock lnep. Yee.,, Pluurb, Leap, h'er; ilei.lnv), Pea
NOTE: This estimate does not include fees due to other Departments(i.e. Planning,Public Works,Fire,Sanitary Sewer District,School
District,etc. . These fees are based on the prelinina information available and are only an estimate. Contact the Dept for addn 7 infa
FEE ITEMS (Fee Resolution 11-053 Ef. 7/1/11) FEE QTY/FEE MISC ITEMS
Plan Check 1,vc,
I
Snppl, 11C Fee
PME Plan Check: $0.00
1 permit Fee
Supp/. Insp Fee
e
PME Unit Fee: $44.00
PME Permit Fee: $44.00
Construction 7i1.
Administrative Fee: 1ADMIN $41.00
Work Without Permit? O Yes (J No $0.00
Advanced Planning f>'ces:
Travel Documentation Fee: ITRAVDOC $44.00
Strong Motion Fee; IBSEISMICR $0.50 Select an Administrative Item
• Bldg Stds Commission Fee: IBCBSC $1.00
SUBTOTALS: $174.50 $0.00 TOTAL FEE: $174.50
Revised: 10/01/2011