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12020002 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10356 N PORTAL.AVE CONTRACTOR:TBD-TO BE DETERMINED PERMIT NO: 12020002 c` DATE ISSUED:02/01/2012 OWNER'S NAME: BREUER ROLF � PHONE NO: OWNER'S PHONE: 4082575293 t'�/y T` l ❑ LIC;ENSED CONTRACTOR'S nECLARaT[oN BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class —T— — O Lino.# G a V MECH RESIDENTIAL ' Contractor COMMERCIAL „1ys-< (14 •F;a�CJ Date Z/ � / Z /� JOB DESCRIPTION:SERVICE IJPGR4DE TO 200AMPS I hereby affirm that I alit licensed under the provisions of Chapter 9 (commencing with Section 1000)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 3'.•00 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:$2500 Section 3700 of the Labor Code,for the performance of die work for which this permit is issued. APN Number:31629007.00 Occupancy Type: APPLICANT C'ERT[FICAT[ON 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 WITHIN 180 DAYS OF PERMIT ISSUANCE OR indemnity and keep harmless the City of Cupertino against liabilities,judgments. costs,and expenses which may accrue against said City in consequence of the 180 DAYS FROM LAST CALLED INSPECTION. granting of this permit. Additionally,the applicant understands and will comply `)—,12/ j2 with all non-pa' ..e regal' ' s per the Cupertino Municipal Code,Section - DateY /�'/ c. 9.13. Issued b� Signature Date /2 ❑ 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 I am exempt from the C'ontractor's License Law for one of installed without first obtaining all 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, Date: will do the work,and the structure is not intended or offered for sale(Sec.7044, Signature of Applicant: Business&Professions Code) L is owner of ttre 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 herebv affirm under penalty of perjury one of the following threeHAZARDOUS 1LiATER[.ALS 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. I 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. Additionally,should I use equipment or devices which emit hazardous air Section 3700 of the Lobar Code,tar 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 I certify that in the pertorntance of the work for which this permit is issued,I shall Health&Safe de,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 Ow er o orized agent: become subject to the Worker's Compensation provisions of the Labor Code,I must Date: 2 � iZ 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 Nam 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 indemnify and keep harmless the City of Cupertino against liabilities,judgments, casts,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 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 CITY OF CUPERTINO 6 ITEMS OF 7 PERMIT RECEIPT OPERATOR: patg COPY # Sec : Twp: Rng: Sub: Blk: Lot: APN . . . . . . . . 31629007 . 00 DATE ISSUED. . . . . . . : 02/01/2012 RECEIPT #. . . . . . . . . BS000015894 REFERENCE ID # . . . 12020002 SITE ADDRESS . . . . . 10356 N PORTAL AVE SUBDIVISION . . . . . . . CITY . . . . . . . . . . . . . : CUPERTINO IMPACT AREA . . . . . . . OWNER . . . . . . . . . . . . : BREUER ROLF ADDRESS . . . . . . . . . . : 10356 N PORTAL AVE CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM . . . . CYNTHIA C FRANCO 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 ---------- ------------- ---------- ---------- ---------- ---------- ---------- 1ADMIN HOURS 1 .00 41 . 00 0 .00 41 .00 0 .00 1BCBSC VALUATION 2, 500 -00 1. 00 0. 00 1 .00 0 . 00 1BSEISMICR VALUATION 2, 500 .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 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- -------- ------------------- -------- ---------------------------- 304 ROUGH ELECTRICAL 103 UFER 505 FINAL ELECTRICAL CITY OF CUPERTINO j FEE ESTIMATOR- BUILDING DIVISION r' ADDRESS: 10356 n. portal ave. DATE: 02/01/2012 REVIEWED BY: bobs. APN: BP#: VALUATION: $2,500 PERMIT TYPE: Electrical Permit PLAN CHECK TYPE: Alteration /Addition/Repair PRIMARY PENTAMATION 1 REAP2 USE: SFD or Duplex PERMIT TYPE: WORK service upgrade to 200 amps. SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Services 1 ERT<200 100 Amps $44 TOTALS: $44.00 Elec.Plan Check 0.0 1 hrs $0.00 Elec.Permit Fee: IEPERMIT Other Elec.Insp. 0.0 hrs $44.00 NOTE: This estimate does not include fees due to other Departments(i.e.Planning,Public Works,Fire,Sanitary Sewer District,School District,etc.). These fees are based on the prelininary information available and are on1v an estimate. Contact the Dept for addn'l info. FEE ITEMS -e,' esc'=:fdt>tr 11-'.3 I'i r %I:'11 FEE QTY/FEE MISC ITEMS PME Plan Check: $0.00 PME Unit Fee: $44.00 PME Permit Fee: $44.00 Administrative Fee: 1 DMIN $41.00 Work Without Permit? 0 Yes (j) No $0.00 Travel Documentation Fee: ITRA VDOC $44.00 tJr011= C 6o IBSEISAKCR $0.50 Select an Administrative Item El tcls fmm>J T ,issi0t) Fee: IBCBSC $1.00 SUBTOTALS: $174.501 $0.00 TOTAL FEE: $174.50 Revised: 1/19/2012 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: /0-3 Poe AVS PERMIT# `� OWNER'S NAME: 2 o L r c t e.r PHONE# GENERAL CONTRACTOR: ZOO/ Sec.S s• �� BUSINESS LICENSE# ADDRESS: q9 o0V A&AA_J A-V-P- CITY/ZIPCODE: *Our municipal code requires all 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 CONTRAGTDAVE OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE. I am not using any subcontractors: '� Signature Date Please check applicable subcontractors and complete the following information: 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 we ontractor Signature Date GENERAL PERMIT APPLICATION MEP COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 2 408 777-3228• FAX(408)T77-3333• building(dicupertino.org misc CUPERTINO ( ) ❑PLUMBING ❑MECHANICAL CZELECTRICAL ❑MISCELLANEOUS PROJECT ADDRESS / S /b /�' 0 f Y-A L A✓'� A # 3 00 -7 PHONE L ^ OWNER NAME 1 Put 2 SCA� STREET ADDRESS CITY, STATE,ZIP FAX _ CONTACT NAME PHONE E-MAIL STREET ADDRESS CITY,STATE, ZIP FAX ❑OwNER Q OWNER-BUILDER ❑ OWNER AGENT JGl CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT CONTRACTOR NAME LICENSE ATLICENSE TYPE BUS.LIC# 7o5t r111 CA CO 00 C — �/� COMPANY NAME S �7" p,,e? EMAIL ^ �A` M S S 2rni �taaa,Cdlh F 7 d0/ Secuv, t a '`r STREET AD S CITY,STATE,ZIP ARCHTTECTIENGINEER NAME LICENSE NUMBER BUS.LIC# COMPANY NAME' E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE USE OF FD or DUPLEX 1:3MULTI-FAMMY PROJECT IN WILDLAND 11YES PROJECT IN ❑YES IS THE BLDG AN C1 YES BUILDING: ❑COMMERCIAL URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑NO EICHLER HOME? ❑NO DESCRIPTION OF WORK L7 -3 � AJJ % J TOTAL VALUATION: L1 `3 n v v� �— RECEIVED BY: By my signature below,I certify to each a 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 p vide is correct., a motion of Work and verify it is accurate. I agree to co ly with all applicable local ordinances and state laws relatiag to buil g c struction� uth presentatives of Cupertino to enter the above-identifi prop for inspection purposes. Signature of Applicant/Agent: vim_ Date: SUPPLOtFENTA INFORMATION REQ=D OFFICE,0 E ONLY OVER-THE-COUNTER ❑ EXPRESS Y U W ❑ STANDARD T U ❑ LARGE ❑ nIAwOR MEPMucApp_1011.doc revised 0 612 1/11