09080002 (2) CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 11800 UPLAND WAY CONTRACTOR:CLAUSEN ELECTRIC INC PERMIT NO:09080002
OWNER'S NAME: BEN LEE 19970 MCKEAN RD DATE ISSUED:08/03/2009
C 'R'S PHONE: 4082187021 SAN JOSE,CA 95120 PHONE NO:(408)927-7322
❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class Lic.# _7q 10/
MECH f— RESIDENTIAL� COMMERCIAL r
Contractor �laust,�(�?e�a1 r/ Date
1 hereby arum that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:REMOVE EXITING PANEL AND REPLACE WITH
(commencing with Section 7000)of Division 3 of the Business&Professions 200AMP NEW
Code and that my license is in full force and effect. SERVICE
I hereby affirm under penalty of perjury one of the following two declarations:
1 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.
I have and will maintain Worker's Compensation Insurance,as provided for by Sq.Ft Floor Area: Valuation:$2850
Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued.
APN Number:36603016.01 Occupancy Type:
APPLICANT CERTIFICATION
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 PERMIT EXPIRES IF WORK IS NOT STARTED
upon the above mentioned property for inspection purposes. (We)agree to save
indemnify and keep harmless the City of Cupertino against liabilities,judgments, WITHIN 180 DAYS OF PERMIT ISSUANCE OR
costs,and expenses which may accrue against said City in consequence of the 180 DAYS FROM LAST CALLED INSPECTION.
granting of this perm Additionally,the applicant understands and will comply
with all non-point s Ge rpgulations�per the Cupertino Municipal Code,Section
9.18• Issued by: _ Date:
v
Sign,pe Date i o
(� OWNER-BUILDER DECLARATION RE-ROOFS:
All roofs shall be inspected prior to any roofing material being installed. If a roof is
I hereby affirm that 1 am exempt from the Contractor's License Law for one of installed without first obtaining an inspection,I agree to remove all new materials for
the following two reasons: inspection.
1,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, Signature of Applicant: Date:
Business&Professions Code)
1,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business&Professions Code). ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
1 hereby affirm under penalty of perjury one of the following three HAZARDOUS MATERIALS DISCLOSURE
declarations:
I have and will maintain a Certificate of Consent to self-insure for Worker's I have read the hazardous materials requirements under Chapter 6.95 of the
Compensation,as provided for by Section 3700 of the Labor Code,for the California Health&Safety Code,Sections 25505,25533,and 25534. 1 will maintain
performance of the work for which this permit is issued. compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
I have and will maintain Worker's Compensation Insurance,as provided for by Safety Code,Section 25532(a)should I store or handle hazardous material.
Section 3700 of the Labor Code,for the performance of the work for which this Additionally,should 1 use equipment or devices which emit hazardous air
contaminants as defined by the Bay Area Air Quality Management District 1 will
permit is issued. maintain compliance with 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 Health&Saf ode,Sections 25505,25533,and 25534.
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 Owner o ized agent: C;
become subject to the Worker's Compensation provisions of the Labor Code,1 must -
Date:_264c
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
APPLICANT CERTIFICATION I hereby affirm that there is a construction lending agency for the performance of work's
I certify that I have read this application and state that the above information is for which this permit is issued(Sec.3097,Civ C.)
correct.I agree to comply with all city and county ordinances and state laws relating Lender's Name
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes.(We)agree to save Lender's Address
it ;fy and keep harmless the City of Cupertino against liabilities,judgments,
cid ..ad expenses which may accrue against said City in consequence of the ARCHITECT'S DECLARATION
granting of this permit.Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section I understand my plans shall be used as public records.
9.18.
Licensed Professional
Signature Date
.zriia CITY OF CUPERTINO
c;?)nr
C U P S IST I NO GENERAL BUILDING
PERMIT APPLICATION FORM
APN# Date:
�� CP0,3oi �• o � `73iLo,
Building Address:
Mo
4/,)4en� /
Mailing Address (if different from Vulding address):
Are Hazardous Materials being used as part of this project? Yes No
HOA: (Exterior work only) Yes No If I es,provide letter from HOA
Owner's Name: Phone#: j�, 7 �� V
Contractor: _ Phone: .
�(1,1f,e!% �T't'- 1 _.IANC. Fax:
Contractor License#: —7
Cupertino Business License#:
Contact: Phone: 0 � (�' -7--73
l�7Q Y�� G( G(1, � Fat: —
Residential Commercial El
Job Description:
,�6 d A-mjq rlp�J 5evv,a-
Building Permit Info: ,�/
Bldg ❑ Elect �t 'lumb ❑ Mech ❑
Type of Construction(Usage Class): Occupancy-Type:
1-A. 1-B IUIII/V-A IUIII B. IV-HT.V-It e3
Valuation: Square Footage:
Project Size: Ex ress tandard Large I 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.orQ
Revised 07/14/09
p. CITY OF CUPERTINO
CITY OF GENERAL BUILIIING APPLICATION
CUPEI�TINO
FEE SCHEDULE
Quantity/Sf Fee ID Fee Des,-.ription Fee Permit Type
Group 1GENRES or
1GENCOM
1STUCOAP Stucco Applications (up to 400 sf) B
additional stucco application
1 WINREP Replacement windows/sliding glass B
door (ea 8 windows)
1 WINMEWSTR New Window-structural shear B
wall/masonry(includes plan ck fee)
IEPERMITFEE Electrical Permit Fee E
1 MPERMITFEE Mechani,:al Permit Fee M
1PPERMITFEE Plumbing;Permit Fee P
1 ELCPLNCK Stand Al one Electric Pln Ck(hourly) E
1MECPLNCK Stand Alone Mechanical Pln Ck(hrly) M
1PLMBLNCK Stand Alone Plumbing Pln Ck (hrly) P
1 STPLNCK-(3 Hr Min Standard Plan Check (when no E/M/P) B
when not over counter) hourly-sl and alone
/ 1BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT
I TYPES
1BSEISMICR Seismic Etesidential B
1BSEISMICO Seismic Commercial B
1 TRAVDOC Travel &;Documentation B
/ 1BUSLIC Business, License B
5 of 5
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
Fax(408)777-3333
CITY OF
.,UPEkTINO
Buildi�777 ant
JOB ADDRESS: PER0� b�
860 (� ��t (Jai
OWNER'S NAME: vt PH7- 7j 3 t-
GENERAL CONTRACTOR: GtG{1`�lt 7�7� FAX # C� `1 7 �(� 46
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and co m Tete the followin information:
60 =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