11120099 . . CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 21902 WOODBURY DR CONTRACTOR:MAINE ELECTRIC INC PERMIT NO: 11120099
OWNER'S NAME: BEVIER LOUISE M 2013 RESEARCH DR DATE ISSUED: 12/16/2011
OWNER'S PHONE: 4082532811 LIVERMORE,CA 94550 PHONE NO:(925)443-3377
Q LICENSED CONTRACTOR'S DECLARATIONgU1LDING PERMIT INFO: BLDG r ELECT r PLUMB rl
License Class C" ic.4 q�' —a 4-G
MECH r RESIDENTIAL r COMMERCIAL r
Contractor Date /-,7 /� Zerr
1 hereby a rat tha am licensed under the provisions of Chapter 9 JOB DESCRIPTION:SERVICE CHANGE OUT AND UPGRADE TO 200AMPS
(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:$5520
1 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:32639022.00 Occupancy Type:
APPLICANT CERTIFICATION
1 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 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, 180 DAYS FROM LAST CALLED INSPECTION.
costs,and expenses which may accrue a said City in consequence of the
granting of this permit. Additionally, a plicanl understands and will comply
with all non-point source regulation the Cupertino Municipal Code,Section Issued by:
9.18.
Signature Date �Z WZ"
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
thereby 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: I 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(a)should 1 store or handle hazardous material.
1 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. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
�8l
I certify that in the performance of the work for which this permit is issued,I shall Health&Safety Cod ctions 25505,25533,and 25534.
not employ any person in any manner so as to become subject to the Worker's Owne or bth zed agent:
Compensation laws of California. If,after making this certificate of exemption,I Date: lz IC ?cry
become subject to the Worker's Compensation provisions of the Labor Code,1 must Jr
forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY
I 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,
costs,and 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 I understand my pians shall be used as public records.
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18. Licensed Professional
Signature Date
H
GENERAL PERMIT APPLICATION M E P
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO,CA 95014-3255 M I C
CUPERTINO (408)777-3228• FAX(408)777-3333•buildinO(dcuoertino.or0
PLUMBING ElMECHANICAL ISELFCMCAL MISCELLANEOUS
PROJECTADDRESS a I,90 Lj Cod /_U. �, APNp 'T .\
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OWNER NAME LPC(NGC. It3-Pv e: PAQMG� S3 Zal/ E-MAM
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CONTA/✓I i(n a�HSo.� (I /.�J /-3;1I sry(I� EMAII.
STREET SS C�. �q CZ SC
S� M %6 FAX
❑OWNER ❑ OWNER-BUILDER ❑JOWNERAGENf KCONTRACTOR ❑CONTRACTORAGENT ❑ ARCNrTECr ❑ENGINEER ❑ DEVELOPER ❑ TENANT
Cji1�TRt1CT0R NAME/ ( C�.t- r^�a �CEy$�E�ND LTM3322SG LIT!YPS q BUB.LICp C7
CO ,Y NAMEK-- e.7YiC �✓f �{/""'w G. L`�CL�iC $�C lab•r/.Du. F
as Y`13-3 7C
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7,STATE P YL/3--3-3 7
ARCHTTECTIENOWEEt NAME LICENSE NUMBER BUS.LIC N
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF SFDmDUPLEX ❑ MULTI-FAMRY PROJECT IN WJLDLAND ❑ YES PROJECT IN ❑YBS IS THE BLDG AN ❑YES
BUILDING: 13 COMMERCIAL URBINTERFACEAN TERFACE AREA ❑ NO FLOOD ZONE [3 No flCHLflI HOME? E3 No
DESCRIPTION OF WORK
Rayl lso
TOTAL VALUATION: S S ICG• CD RECEIVED BY:
By my signaturo below,I certify to each of the following: am the property owner or authorized agent to act on the property owner's behalf. I have read thus
application and the information I have provided i come �have reed[Is Description of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating m buil - c Smrc' v I authorize representatives of Cupertino to enter the above-idendficd property for inspection pull ores.
Signature of Applicant/Agent: Date: 1't �6 a"'lCgl
SUPPLE AL INFORMATION REQUIRED OFFICE USE ONLY
❑ OVER-THE-COUNTER
6
❑ EXPRESS
m
❑ STANDARD
u
.. _ ❑ LARGE
❑ MAJOR
MEPMucApp_2011.doc revised 06121111 -
CITY OF CUPERTINO
6 ITEMS OF 6 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 32639022. 00
DATE ISSUED. . . . . . . : 12/16/2011
RECEIPT #. . . . . . . . . : BS000015587
REFERENCE ID # . . . : 11120099
SITE ADDRESS . . . . . : 21902 WOODBURY DR
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : BEVIER LOUISE M
ADDRESS . . . . . . . . . . : 21902 WOODBURY DR
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014-1148
RECEIVED FROM . . . . : MARK JOHNSON
CONTRACTOR . . . . . . . : SCOTT MAMOLA LIC # 32671
COMPANY . . . . . . . . . . : MAINE ELECTRIC INC
ADDRESS . . . . . . . . . . : 2013 RESEARCH DR
CITY/STATE/ZIP . . . : LIVERMORE, CA 94550
TELEPHONE . . . . . . . . : (925) 443-3377
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 5, 520 .00 1. 00 0 .00 1 .00 0. 00
1BSEISMICR VALUATION 5, 520 .00 0.55 0 . 00 0 .55 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 .55 0 . 00 174 .55 0. 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CREDIT CARD 174 . 55 VISA
---------------
TOTAL RECEIPT 174 .55
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
103 UFER 304 ROUGH ELECTRICAL
505 FINAL ELECTRICAL
CITY OF CUPERTINO
FEE ESTIMATOR—BUILDING DIVISION
ADDRESS: 21902 woodway dr. DATE: 12/16/2011 REVIEWED BY: bobs.
APN: BPk: `VALUATION: $5,520
*PERMIT TYPE: Electrical Permit PLAN CHECK TYPE: Alteration /Addition/ Repair
PRIMARY SFD or Duplex PENTAMATION 1REAP2
USE: PERMIT TYPE:
WORK service Cahn a out and upgrade to 200 amps
SCOPE
APPLIANCE EQUIP TYPE FEE ID QTY UNITS BP FEES
Services 1ERT<200 200 Amps $44
TOTALS: $44.00
:ve,h. Plmr Chack I'lunrlr.Plan Cheek Elec.Plan Check 0.0 1 hrs $0.00
tMe(A 11"I'tit Pave: Plumh. l'cemrr lqx: I Elec. Permit Fee: IEPERMIT
i the..11,.•o h.Insp. rather I lamb brcp. Other Elec.Insp. 0.0 hrs $44.00
Ai"J, Imp, Fee: Plumb, b"p. Fear: Elec.Ing?. Fee'
NOTE: This estimate does not include fees due to other Departments(Le.Planning,Public Works,Fire,Sanitary Sewer District,School
District etc. . These fees are based on the prelinina in ormadon avai(ab(e and are only an estimate. Contact the Dept foraddn7Info.
FEE ITEMS (Fee Resolution 11-053 EYf 71LI it FEE QTY/FEE MISC ITEMS
Plan Check Fee:
.Sxpi�l. P<'fee
PME Plan Check: $0.00
/'omit Fee:
Suppl. lasp Fae
PME Unit Fee: $44.00
PME Permit Fee: $44.00
Construction nix:
Administrative Fee: (ADMIN $41.00
Work Without Permit? O Yes (F) No $0.00
�l.ircrncerl plarminr Fees:
Travel Documentation Fee: ITRAVDOC $44.00
Strone Motion Fee: IBSEISMICR $0.55 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $1.00
SUBTOTALS: $174.55 $0.00 :, ,, TOTAL FEE. $174.55
Revised: 12/04/2011
Building Department
City Of Cupertino
10300 Torre Avenue
Cupertino,CA 95014-3255
Telephone: 408-777-3228
C U P E RT I N O Fax: 408-777-3333
CONTRACTOR/ SUBCONTRACTOR LIST
JOB ADDRESS: `d/you pill PERMIT#
OWNER'S NAME: L ovine 8 evie. PHONE# " 77
77
GENERAL CONTRACTOR: ,PPNai, EGA li+c. BUSINESS CENSE# 32C7/
ADDRESS: 5Y19 Z—d/If r.�� CITY/ZIPCODE: 94157-1
*Our municipal code requires all businesses working in the city to have a City of Cupertino business license.
NO BUILDING FINAL OR FINAL OCCUPANCY INSP TION(S) WILL BE SCHEDULED UNTIL THE
GENERAL CONTRACTOR AND ALL SUBCONTRA S HAVE OBTAINED A CITY OF CUPERTINO
BUSINESS LICENSE.
am not using any subcontractors:
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
Owner/Contractor Signature Date