08120113 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTReiCT(1RI'NFORMATIOl;
BUILDING ADDRESS: PERMIT NO.
21793 OLIVE AVE A-1 -ELECTRIC
OWNER'S NAME: PERMIT L95UE DATE
NE: SAN CONTROL NO.
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
UPGRD ELECTRCL SVC 60AMP - BLDG ELECT PLUMB MECH
O O O O
goc LICENSED CONTRACTOR'S DECLARATION 100AMP Job Description
W 1 hereby af0m that 1 am licensed under provisions of Chapecr 9(commencing
with Section 70011)of Division 3 of the Business and Professions Code.and my license is
m• in full toren and cfrtty
License Clew `•—s0 Lk.N le
=q Date 11—al—csie Conttacor —t9 �' .T
p 7W7th ARCHITECTS DECLARATION
W U I understood my plans shall W toed u public records
g t In Lammed pmressional
yO3 OWNER-BUILDER DECLARATION
F 1 hereby affirm that 1 am exempt from to Conuaaors License Law rar Ne
a oy fallowing reawn.(Section 7(n 1.5,Buri sss and Pmfeuimu Cade:Any city or mmnry
which¢qres uia pmmrove
it he momwc4 alter.imp .demollah,a¢pair any mem.
uZY prior us its LRuaMe.aka requires the applicant(or Such permit to rile a signed Slalmonl
mm< that he isliccmdpursuant othe Provisions Ofthe COntaemr3lJaneLaw(Chapter9 Sq. Ft. Floor Area Valuation
yF$ (commencing with Smuon 7")of Division 3o the Business and Pmfeaions Code)or
that W Is exempt therefrom and Ne bask for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant m a civil Penalty of APN Number - Occupancy Type
Out mart than five hundred dollus(55(10).
I,u owner of tW property,a mY employcu wird wage as 1W"v ask compensation,
will do the work and tW smcmrt is notimended or offered formle(Sec.7044,Business
and Professions Cade:The Contracmrs Liatue law doer Out apply to an Owner or Required Inspections
property who WildsorimProves thereon,and who dassuch werkhimelfOrthough his
own employees.provided that such improvements art not intended oroRcrW for ale,If.
however.Ne building or improvement is sold within one year of compkum,the Owner-
builder will have the burden of proving Nat W did ser build or improve for purpose of
aky
0 I,as owner of dte property,am exclusively contracting with licensed contractors to
consuat Ne projed(Sec.7044,Business and Profeasio a Cade:)The Grimacers Li-
move law does not apply to in owner of property who Wilda or improves Merton.and.
who contracts far such projems with sen...cMB)licensed pursuant w Ne Contrusors
License law.
0 1 ons aempt under S. .B h P C for this mown
Owner Dale
WORKERS COMPENSATION DECLARATION
Wreby.trim under petalty or perjury are ofthe fallowing daclautions:
award
will mainuin•Certificate of Consent to sel6h sure for Worker'sCompen-
en,as provided for by Seetion 3700 of the labor Code,for the performance of de
wort for which this permit is issued.
0 1 have and will maintain Workers Compensation Insurance,as requited by Section
3700 of the labor Code,for the performance of lW work for which this permit is is ad. '
My Work s Compensation Im nano artier and policy MOOWI are:
Cartier. E1 Ea1 Policy NnW K N sLJY Iq�
CERTIFICATE OF ( PTION FROM WORKERS'
COMPENSATION INSURANCE
(nossm(on need nmhecanpleed if the permit is forom hundred dollars(3100)
or less.)
I certify that in the peffomanee of 1W wart far which this permit k issued.I stall not
employ any person in any mmmrm as m Wcomc subject to the Workers''Compensaua
Laws of California Date
Applicant
NOTICE TO APPLICANT:IL after mating this Certificate of Exemption.you should
became subject to the Workers Compensation provisions of Ne LaWr Code.you must
O feMwith sins comply with such provioor this omit shall W deemed revoked.
) CONSTRUCTION LENDING AGENCY
'r. 1 hereby arum Nat Vert k a construction lending agency far the per(omanm of
!Yithe work for which this permit is issued(Sec.3M,Civ.C.)
Uj 0 Lender's Name
.7. z Lenders Addmu
U Q I anify that I have read his applicuion and sum that the above irtiomatiun k
IL comet 1 agree m comply with all city and county rudiments and sue laws miming In
0 building construction,and hereby euthotim mpmsenutiwrs of Nis city w enter upon Ne
W above-nomduned property for inspection purposes
(We)agree to ave,indemnify and kap hamlets lW City of Cupertino against
crI liabilities judgments,costs and expenses which may in any way am=against aid City
U z in wnrcgucnce of doe,granting of this pemiL
^� APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
3 EREGULATI�
t1-0Date Re-roofs
Signuurt of ApplipHAZAR mOr Dau
HAZARDOUS MATERIALS DISCLOSURE Type Of Roof
Will the a Cupertino
a future Wilding occupant stain aandhandle o h unth as material
u defined by the Cupertino Municipal Code.Chapter 9.13,and tW Health and Safety '
Code,Section255320)? All roofs shall be inspected prior to any roofing material being installed.
0y. 1ple
Will du applicant or futons Wilding aavpant ton equipment or devise which If a roof is installed without first obtaining an inspection,I agree to remove
havallom air mmaminacs u deli.!by Ne Bay Area Air Quality Management all new materials for inspection.
et
❑Yes Nu
I have mal Ne haaOdoa materials requirements umle,Chapter 6.95 of the Caifm-
Ma Heal"SafetyCoce.Somimu 25505.25533 and Z534.I undimmed con if the batihfing
does Oat comedy haw a="L that it is MY responsibility m notify the occupant of de
egwtements which must W metprior mhohouse,lnora Ccrdricateof Occupancy' Signature of Applicant Date
Owner err aatharirnd,gent Da i l All roof coverings to be Class'W'or better
CITY OF CUPERTINO
�4 ITEMS OF 9 PERMIT RECEIPT OPERATOR: pdtg
COPY # 1
Sec : Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . .. 35718029 . 93
DATE ISSUED. . . . . . . : 12/17/2008
RECEIPT # . . . . . . . . . : BS000006839
REFERENCE ID # . . . : 08120113
SITE ADDRESS . . . . . : 21793 OLIVE AVE
SUBDIVISION . . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . .. ROGER SY
ADDRESS . . . . . . . . . . : 21793 OLIVE AVE
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
RECEIVED FROM . . . . : A-1 ELECTRIC
CONTRACTOR . . . . . . . : ROBERT LAMANTA LIC # 27061
COMPANY . . . . . . . . . . : A-1 ELECTRIC
ADDRESS . . . . . . . . . . : 421 E HEDDING ST
CITY/STATE/ZIP . . . : SAN JOSE, CA 95112
TELEPHONE . . . . . . . . : (408) 975-9171
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
1BSEISMICR VALUATION 1, 500 . 00 0 . 50 0 . 00 0 . 50 0 . 00
1EPERMITFE FLAT RATE 1 . 00 40 . 79 0 . 00 40 . 79 0 . 00
1ERT<200 UNITS 1 . 00 40 . 79 0 . 00 40 .79 0 . 00
1TRAVDOC FLAT RATE 1 . 00 40 . 79 0 . 00 40 .79 0 . 00
-- ---------- ---------- ----------
TOTAL PERMIT 122 . 87 0 . 00 122 . 87 0 . 00
Community Development
10300 Torre Avenue
? �Y Cupertino CA 95014
. Telephone(408)777-3228
CITY OF Fax(408)777-3333
4UPEI�TINO
Building De artment
JOB ADDRESS: PERMTT #
2A '19
OWNER'S NAME: PHONE #(gyp a-
GENERAL CONTRACTOR: FAX #
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following ' ormation:
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
Owner/Contractor Signature Date
v Ila
.CG.G.,. CITY OF CUPERTINO
. CUPEk11No GENERAL BUILDING
PERMIT APPLICATION FORM
APN # nO�n, I121
Building Address: Q 7
rD-1"19 3 d l 1 v =
Mailing Address (if different from building address):
Owner's Na} !: hone#:
\moo �a S WSb 114 aS---7
Contractor: Phone:4v8 cj-'7 S-ki 1 ^( 1
Fax: 6�
Contractor License#: zj o 1tk"l
Cupertino Business License#: a1 Oro
Contact: Phone:
C�o l{ gRS�t 1"1
• Residential Commercial Fax:
J`ob`Description: c
Building Permit Info:
Bldg ❑ Elect Plumb ❑ Mech ❑
Type of Construction (Usage Class): Occupancy Type:
1-A, 1-B ❑ II/III/V-A ❑ IUIII B, IV-HT, V-B ❑i 4� 3
Valuation: C,j Square Footage:
Project Size: Ex ress Standard ❑ 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
Revised 10/20/08
aCITYF
CITY OF CUPERTINO
CUPERTINO GENERAL BUILDING
PERMIT APPLICATION FORM
Quantity/Sf Fee ID Fee Description Fee Permit Type
Group 1GENRES or
1GENCOM
1 BBOILERI For the installation or relocation of ea M
boiler/compressor to & including 3
horsepower, or ea absorption sys to &
incl 100,000 Btu/h (29.3kw)
1 BBOILER2 Installation /relocation of ea M
boiler/compressor over 3 horsepower
to & incl 15 horsepower, or ea
abso tion sys over 100,000 Btu/h
1 BBOILER3 Installation/relocation of ea M
boiler/compressor over 15 horsepower
to & incl 30 horsepower, or ea
absorption sys over 500,000 Btu/h to
& incl 1,000,000 Btu/h
1 BBOILER4 Installation/relocation of ea M •
boiler/compressor over 30 hosepower
to & incl 50 horsepower, or for ea
absorption sys over 1,000,000 Btu/h to
& incl 1,750,000 Btu/h
1 BBOILER5 Installation/relocation of ea boiler or M
refrigeration compressor over 50
horsepower, or ea absorption sys over
1,750,000 Btu/h
1 BAPPLOTH For ea appliance or piece of equip M
regulated by this Code but not classed
in other appliance categories, or for
which no other fee is listed in this
code.
IELECINSP Other Electrical Inspections (per hour) E
1MECHINSP Other Mechanical Inspections (per M
hour)
1PLMBINSP Other Plumbing & Gas Inspections P
(per hour
1 MEETING]HR Application Meeting B •