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CITY OF CUPERTINOp,:
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BUILDING DIVISION PERMIT
COIFa , "GT TR INPORMA I0 .
r✓�59.�u. "a x,_',. �Rst;;,a"3k �i8m-._;s:a,u•,y�
BUILDING ADDRESS:
PERMIT NO.
101.20 N DE ANZA BLVD
TBD — TO BE DETERMINED
08080224
OWNER'S NAME:
PERMIT ISSUE DATE
SP. JOSEPH CHURCH
08/28/2008'
NE:
SANITARY NO. CONTROL NO.
ARCHIT (ENGINEER:
BUILDING PERMITINFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
Vichy .dorm lhal l am liccuroed under provisions of Chapter 9 (commencing
wflh Scene. 7 fB)of Division 3.fMe, Beat. and Professions Code, and my license is
TEMP POWER
in full force and sRca
License Clan Lie. is
Dale Contractor
ARCHITECTS DECLARATION
I understand my Plana Shell he used As public records
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby aRm that I am exempt from the Contractors License Law for the
following reason. (Section 1051.5, Business and Professions Code: Any city or. county
which requires a permit to mosuuct shot. improve. demolish, or repair my structure
prior On its issuance. alar, requires lheap'licant for such pemit to file aligned snclum,
mat he is licensed pursuant the provisions of the contractors Uanse Law (Chip= 9
Sq. Ft. Floor Area Valuation
(commencing with Section 1000) of Division 5 of she Business and Prof ions Code)or
$3000
Must he is exempt themrrom and the basis far the alleged nempdwn. Any violation of
Section 7113 1.5 by any applicant for a permit subjects the applicant to a civil penny or
Number
Occupancy Type
ot mom than fvc hundred dollars (vse
11.62 6 093
❑ I, as Mmes of the property. or my emplayees with wags As sheir sole compensation,
Aril] da ase wort. and the stnetern BOut intended orofm ed forsam (Sec. 1044, Burioau
W
And Prorcasions Cases: Tcontractor anto n to cLaw doant apply an owner a
Required Inspections
property woo Wdaam improves thucon,ana wnoaoessuen work nimecvm tbroogh his
own empbyrus, proNdeO mal such impmvemanu art oat inreMrd oroaertd forsas. U.
however, Nebuildingwimprovement4haltwithinct youverimprovford¢vsvar-
WiWer will have the buNea of purring sur W did rot dtiM a improve far Purpose of
lase].
fgri. As owner, of the property am crclusively contracting with licensed tmmwcmrs to
construct the project (Sec. 10/4, Business and Professions Code:) The Comeaetors Li.
CenY Law does not apply to an awnm Of property who builds or improves meRAn, and
who contracts for such projects with a conuanor(s) licensed pursuant to the Contractor's
License Law.
❑ lames cm tundra See ,B a P C far this rtuon
,11 � �
Owner/y..�. �AxN`^' Dain
WORKER'S COMPENSATION DECLARATION
1 hereby afnmr under penalty of perjury, arc of the following declmtions:
1 have and will maintain • Contifica eof Conant to self-buurt fa Wer crsCampen-
Asian, as provided far by Section 5100 a the labor Cadl four the performance at the
work for which this permit is issued.
1 have and will maintain Workers Compensation hsurance, As required by section
5100 of me later Cade. for the performance of the work forwbich this permit is Wood.
'
My Worker's Campuwlion Inman carrier Audi Polity number Are:
Carrier: Policy Na:
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
(This section need rot W completed if the permit U franc hundred dollar. ($IBM
m leas)
1 minify that in the porfoamarte a use work fm which this permit is issued, l atW1 not
mrPloy any lexan In my mor An as b haeme subject in the WMears'Coe,sox ion
laws of Califorpy, Dau
APPlicant
NOTICE TO APP CA : If, after mating this Cc tiftesm of Exemption. you should
become subject M me Workers Campemilien Provisions of the lobar Code, you most
fanbwith comply with each Provisions or this peTit shall k deemed! revoked.
CONSTRUCTION LENDING AGENCY
I Wsehy affim mat Vert is a consuuction lending agency for the varfomance of
dsc work for which d s perch is issued (Sec. 5091. Civ. C.)
Lenders Name
Lemicea Address
I cmdfy that I have un d this application and state that the shave information is
comet, I .gra to comply with all city and county eNinames and sou Lem slating M
building construction. and hereby aumarias uprexnuuvrs of this city to enter upon the
.pare-menwma property ran inspection ptrryoua
(We) agree to save, indemnify and kapm
haless the City of Cupertino against
liabilities, judgments, casts and expenses which may in anyway Decreaseagaiast laid City
in mosegn oof the pursing of this Permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SO S'..
l
Issued by: DateREGULATIONC2 —(/—/%%
1/�^+I+JWN
Foto
Re -roofs .
Signnuma AppranotCootr�l�
HALtRDOUS MATERIALS DISCLOSURE
Type of Roof
Will the appllanl or fume Wilding occupant amu no handle haaardon material
An defined by he Cupcomo Municipal Code. Chapter 9.13- and the Health and Safety
cane,snY. 255524jt
❑ res o
All roofs shall be inspected prior to any roofing material being installed.
w,n be applicant m metre Wilding occupancy equipment of dew;® whiten
If a roof is installed without first obtaining an inspection, I agree to remove
g P
s air conumimns u defined by me Bay Arta Air Quality Managcmcnl
A
all new materials for inspection.
Disuim!?
DYo 1�0No
1 havereal me NaaNws m=Hala mquimmcnuunder Chapmr6.95ofine C.lifor.
niaHnlmaSef ty Cada Seedmu ZM5, 35533 am 3 5M.1 undersand Ihuif dm Wilding
don nm mocully have a orant INt It is my tospcondlity M antily thn oa.W, of the
rtyuirtwwny. icn.nuabemetpriarmissf Ceoffil.01 Occupancy.
Signature of Applicant Date
All roof coverings to be Class ';W' or better
Owner or authorind ag^gent, Dato'
CITY OF CUPERTINO
• 4 ITEMS OF 4 PERMIT RECEIPT OPERATOR: patg
COPY # : 1
Sec: Twp: Rng: Sub:
Blk: Lot:
APN ........:
11626093:00
DATE ISSUED.......:
08/28/2008
RECEIPT #.........:
BS000005927
REFERENCE ID # ...:
08080224
SITE ADDRESS .....:
10120 N DE ANZA BLVD
SUBDIVISION .......
CITY .............:
CUPERTINO
IMPACT AREA .......
OWNER ............:
ST. JOSEPH CHURCH
ADDRESS ..........:
10120 N DE ANZA BLVD
CITY/STATE/ZIP ...:
CUPERTINO, CA 95014
RECEIVED FROM ....: BRIAN EDEM
CONTRACTOR .......: TBD - TO BE DETERMINED LIC # 00096
COMPANY ..........: TBD - TO BE DETERMINED
ADDRESS
CITY/STATE/ZIP .... ,
TELEPHONE ........:
• FEE ID UNIT QUANTITY AMOUNT PD -TO -DT THIS REC NEW BAL
IBSEISMICO VALUATION
3,000.00
0.63
0.00
0.63
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
1.'PRAVDOC FLAT RATE
1.00
------
40.79
0.00
40.79
0.00
TOTAL PERMIT
123.00
------
0.00
----------
123.00
----------
0.00
METHOD OF PAYMENT
-----------------
CHECK
TOTAL RECEIPT
AMOUNT
---------------
123.00
---------------
123.00
VOICE Ill DESCRIPTION
-------- ----------------------------
402 TEMPORARY POWER
REFERENCE NUMBER
--------------------
#5482
VOICE ID DESCRIPTION
-------- ----------------------------
Aq,YOF,
•
CUPEI�TC"RT
INO
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ado Pa;� y
CITY OF CUPERTINO
TEMP POWER
PERMIT APPLICATION FORM
APN # -� 1
�-�
Fee ID
r ��
62�0 93.
�,—►--i/
Date
Building Address:
1D12-0
r�,za. ELVGL
1ERT>1K
Owner's Name:
11 ,
4 C�AP%UHolz-:;Sa-�y�ll
Phone #:
Contractor: I
Res. Temp Power <200
Amps
c �Lec*ri ca& �r , +k e,
C C, L
Phone #:
1 ERT2001 K
7J C ommunt� W
E
blas 5 r i,ce5
Fax #:
Contact:
S h.akli a-
-0 i,, r i e.r-•
Phone #:
4cjq - 52 - y (70
Contractor License #:
Electric Plan Check
E
Cupertino Business License #:
/
Job Description:
Seismic Residential
l
IQ/K�
St, 3�5eph
of
CuPer�Lr�o F,,1 1y ��� FeSftVa a�vvJQ✓
Residential ❑
I 1 �Y1er or pwe
Commercial
by Oi,eSeL
Valuation (cost of project):
Ci�2
� �
3
0w
Quantity
Fee ID
Fee Description
Fee Group
Permit Type
1ERT>1K
Res. Temp Power >IK
Amps
E
1REAP14
IERT<200
Res. Temp Power <200
Amps
E
1 ERT2001 K
Res. Temp Power 200-1 K
Amps
E
IEPERMITFE
Electric Permit Issuance
E
1 ELCPLNCK
Electric Plan Check
E
/
1BSEISMICR
Seismic Residential
B
/
1TRAVDOC
Travel & Documentation
Fee
B
v
�� 'cYt✓
CITY Of
CUPEkTINO
CITY OF CUPERTINO
TEMP POWER
PERMIT APPLICATION FORM
Quantity
Fee ID
Fee Description
Fee Group
Permit Type
IBSEISMICO
Seismic Commercial
B
10EAP14
IECT<200
Commercial Temp Power
<200 Amps
E
1 ECT> 1 K
Commercial Temp Power
>lK Amps
E
IECT2001K
Commercial Temp Power
100-1K Amps
E
1TRAVDOC
Travel & Documentation
Fee
B
1BUSLIC
Business License
B
0
•
0
�5 I ,F J
CITY OF
WUPEkTINO
•
•
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone (408) 777-3228
Fax (408) 777-3333
Building Department
JOB ADDRESS:
Do= VCaDe4inor'I,
PERMIT #
2n N.
BUSINESS NAME
OWNER'S NAME: ef CA Ano nog
PHONE # L{ _a,5
GENERAL CONTRACTOR. e
FAX # [{ pg
I am not using any subcontractors: ' -n� 0-a—C
Signature Date
Please check applicable subcontractors and complete the followinginformation:
Owner/ Contractor Signature
Date
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