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11120109 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 22045 REGNART RD CONTRACTOR:G.M. ELECTRIC PERMIT NO: 11120109 OWNER'S NAME: ROBERT BIGLER 535 BOBBY'S LN DATE ISSUED: 12/21/2011 OWNER'S PHONE: 7068175984 HOLLISTER, CA 95023 PHONE NO:(408)592-5306 LICENSED CONTRACTOR'S DECLARATION // BUILDING PERMIT INFO: BLDG F_ ELECT PLUMB F License Class _ Lic.# 7 S 6 4 � 9 � ` f MF.CFI RESIDENTIAL COMMERCIAL \ Contractor r l P !6 C —Date /a-9.1" JOB DESCRIPTION: TEMP POWER POLE I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000)of Division 3 of the Business&Professions Code and that my license is in full force and effect. I 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:$650 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 APN Number:36646004.00 Occupancy Type: permit is issued. APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED correct.I agree to comply with all city and county ordinances and state laws relating WITHIN 180 DAYS OF PERMIT ISSUANCE OR to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We)agree to save 180 DAYS FROM LAST CALLED INSPECTION. indemnify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City in consequence of the granting of this permit. Additionally,the applicant understands and will comply Issued hJ " Date: e with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. RE-ROOFS: Signature hzu, Date/g- All roofs shall be inspected prior to any rooting material being installed. If a roof is installed without first obtaining an inspection,I agree to remove all new materials for inspection. OWNER-BUILDER DECLARATION Signature of Applicant: Date: I hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER I,as owner of the property,or my employees with wages as their sole compensation, 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 HAZARDOUS MATERIALS DISCLOSURE construct the project(Sec.7044,Business&Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the California Health&Safety Code,Sections 25505,25533,and 25534. I will I hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the declarations: Health&Safety Code,Section 25532(a)should I store or handle hazardous I have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally,should 1 use equipment or devices which emit hazardous Compensation,as provided for by Section 3700 of the Labor Code,for the air contaminants as defined by the Bay Area Air Quality Management District 1 performance of the work for which this permit is issued. will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Secti ns 25505,25533,and 25534. Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agent: Date: permit is issued. I certify that in the performance of the work for which this permit is issued,1 shall not employ any person in any manner so as to become subject to the Worker's Compensation laws of California. If,after making this certificate of exemption,I CONSTRUCTION LENDING AGENCY become subject to the Worker's Compensation provisions of the Labor Code,I must I hereby affirm that there is a construction lending agency for the performance of forthwith comply with such provisions or this permit shall be deemed revoked. work's for which this permit is issued(Sec.3097,Civ C.) Lender's Name APPLICANT CERTIFICATION Lender's Address I certify that I have read this application and state that the above information is 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 upon the above mentioned property for inspection purposes.(We)agree to save ARCHITECT'S DECLARATION indemnify and keep harmless the City of Cupertino against liabilities,judgments, and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records. .sting of this permit.Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code,Section Licensed Professional 9.18. Signature Date GENERAL PERMIT APPLICATION MEP COMMUNITY DEVELOPMENT DEPARTMENT-BUILDING DIVISION 10300 TORRE AVENUE-CUPERTINO, CA 95014-3255 CUPERTINO (408)777-3228-FAX(408)777-3333- building c( cupertino.orq M 'SIC ❑PLUMBING ❑MECHANICAL IRELECTRICAL ❑MISCELL OUS PROJECT ADDRESS APN# !) / _(! /� o 1 OWNERNAMEPH NE E-MAIL e r G � STREET ADDRESS ISap O Q, �4�Q� CITY, STATE,ZIP / FAX CONTACT NAME , C o PH NE _ E-MAIL ej— STREET ADDRESS CITY,STATE, ZIP FF ❑OWNER ❑ OWNER-B=ER ❑ OWNER AGENT ❑ CONTRACTOR ❑CONTRACTORAGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT CONTRACTOR NAM LICENSE NUMBER LICENSE TYPE BUS.LIC# v, F C'-16 -756O COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE ARCHTTECT/ENGINEER NAME LICENSE NUMBER BUS.LIC# COMPANY NAME' E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE JSE OF Iff SFD or DUPLEX ❑ MULTI-FAMILY PROJECT IN WIIALAND ❑ YES PROJECT IN ❑YES IS THE BLDG AN ❑YES BUILDING: ❑COMMERCIAL URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑NO EICHLER HOME? ❑NO DESCRIPTION OF WORK e 6 0 r9 n1 TOTAL VALUATION: RECEIVED BY: By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on the property owner's behalf. I have read this application and the information I have provided is correctj have read the Description of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating to it 'ng constructi n. I a o'ze representatives of Cupertino to enter the above-identified property for inspection pu{poses. Signature of Applicant/Agent: Date: la . 1 SUPPLEMENTAL INFORMATION REQUIRED OFFICE USE OILY •R-THE-COUNTER ❑ EXPRESS Y U o-7 ❑ STANDARD r U ❑ LARGE 4 ❑ MAJOR MBPMiscApp_2011.doc revised 06121111 CITY OF CUPERTINO 6 ITEMS OF 6 PERMIT RECEIPT OPERATOR: SylviaM COPY # 1 Sec : Twp: Rng: Sub: Blk: Lot : APN . . . . . . . . : 36646004 . 00 DATE ISSUED. . . . . . . : 12/21/2011 RECEIPT # . . . . . . . . . BS000015604 REFERENCE ID # . . . : 11120109 SITE ADDRESS . . . . . : 22045 REGNART RD SUBDIVISION . . . . . . CITY . . . . . . . . . . . . . . CUPERTINO IMPACT AREA . . . . . . OWNER . . . . . . . . . . . . : ROBERT BIGLER ADDRESS . . . . . . . . . . : 11230 BUBB RD CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM . . . . : G. M ELECTRIC CONTRACTOR . . . . . . . : GARY GARCIA LIC # 31311 COMPANY . . . . . . . . . . : G.M. ELECTRIC ADDRESS 535 BOBBY' S LN CITY/STATE/ZIP . . . : HOLLISTER, CA 95023 TELEPHONE . . . . . . . . : (408) 592-5306 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 650 . 00 1 . 00 0 . 00 1 . 00 0 . 00 1BSEISMICR VALUATION 650 . 00 0 . 50 0 . 00 0 . 50 0 . 00 1EPERMITFE FLAT RATE 1 . 00 44 . 00 0 . 00 44 . 00 0 . 00 1ERT<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 ----------------- --------------- -------------------- CREDIT CARD 174 . 50 MC --------------- TOTAL RECEIPT 174 . 50 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 402 TEMPORARY POWER Building Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014-3255 Telephone: 408-777-3228 "U P E RT I N O Fax: 408-777-3333 CONTRACTOR/ SUBCONTRACTOR LIST 11-4 JOB ADDRESS: a °� �j ec PERMIT# OWNER'S NAME: PHONE# SA Sid GENERAL CONTRACTOR: m, c-f r /'C- BUSINESS LICENSE# ADDRESS: S 's � 2 CITY/ZIPCODE: *Our municipal code requires al businesses working in the city to have a City of Cupertino business license. NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE GENERAL CONTRACTOR AND ALL SUBCONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE. I am not using any subcontractors: 9 6 1 Signature Date Please check applicable subcontractors and complete the following information: V SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets & Millwork Cement Finishing Electrical Excavation Fencing Flooring / Carpeting Linoleum /Wood Glass / Glazing Heating Insulation Landscaping Lathing Masonry Painting /Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile &' V Owner Contractor Signature Date