12030127 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 20376 VIA NAPOLI CONTRACTOR: E G ELECTRICAL PERNIff NO: 12030127
SERVICES
OWNER'S NAME: RENATO ROSCHER JR 1170 BISMARCK DR DATE E ISSUED;03/26/2012
OWNER'S PHONE: 4089731636 CAMPBELL,CA 95008 PHONE NO:(408)370-2222
❑ LICENSED CONTRACTOR'S DECLARATION � r r
/ I^ BUILDING PF:R\11'1' In
INFO: .nc ELECT" PLG>IR
License Class Lic.q T(O n J��
NIF-CII RESIDEN"PIAL COMMERCIAL.
Contractor Dale
I hereby a1Tir nt I rod under the provisions of Chapter 9
JOB DESCRIPTION` INSTALL GI'CI PRO'1'1'-C'I'IiD OU3'I.Ii'1'IN CRAWL.SPACE
(commencing with Section 7000)of Division J 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 rive,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:S500
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 APV Number:31601136.00 Occupancy Typr:
pernil 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.1 agree to comply with all city and county ordinances and state laws relating WITHIN 180 DAYS OF PERMIT ISSUANCE OR
m budding construction,and hereby authorize representatives of this city to enter
upon the above mentioned property Ibr inspection purposes. (We)agree to save 180 DAYS FROM LAST CALLED INSPECTION.
indemnifv and keep harmless the City of Cuperino against liabilities,judgments.
costs,and expenses which may acerae against said City in consequence oflhe
granting of this per . Additionally.the applicant understands and will comply Issued by:
with all non-point so cc regulations per the Cupertino Municipal Code.Section
9.18,
RE ROOFS:
Signature Dale All roofs shall be inspected prior to any roofing material being installed If'a roof is
installed without lirsl obtaining an inspection, I agree to remove all new materials fix
inspection.
❑
OWNER-BUILDER DECI.ARA'I'ION
:
I hereby affirm that nm exempt from the Contractor's License Law for one of Signature of ApplicantDale:
the following two reasons: AIA,ROOF COVERINGS TO BE CLASS"A"OR BE 1-1ER
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(Sce.7044.
Business&Professions Code)
I,as Owner of the property,am exclusively contracting with licensed contractors to II:\%ARDOUS NIA'I'ERIAI S DISCLOSURE
construct the project(Sec.7044,Business&Professions Code). I have rend the hazardous materials requirements under Chapter 6.95 of the
California Ilealth&Safety Code,Sections 25505,25533,and 25534. twill
hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
declarations: Ilealth&Satiety Code.Section 25532(a)should I stare or handle hazardous
I have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally,should I use equi rent or devices which emit hazardous
Compensation,as provided for by Section 3700 of the Labor Code,for the air contaminants as defined by the[
•a Air Quality Management District
performance of the work Ibr which this permit is issued will mnintain compliance with the Cup Lino Municipal Code Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Ilealth&Safety( de,Sections 5,25533,and 25534.
Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agent: Dale:
permit is issued.
I certify that in the performance of the work for which Oris permit is issued,I shall
not employ any person in any manner so as to become subject to the Worker's
Compensation laws of California. If,alter making this certilicale of exemption,I CONST'RUCT'ION LENDING AGENCY
become subject to the Worker's Compensation provisions of the labor Code,I must I hereby allirnr that there is a construction lending agency I. the perl'urmance 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.)
Lemder's Name
AI'PI.ICAN'1'CER'TIFICA'TION Lender's Address
I certify that I have read this application and stale that the above information is
correct. I agree to comply with all city and county ordinances and stale laws relating
to budding construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes,(We)agree to save ,\RCIIITECI"S DF.C.LARA'1'ION
indemnify and keep harmless the City'of Cupertino against liabilities',judgments,
costs,and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records,
graining of this permit.Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section Licenscd Professional
9.18.
Signature Ilan
CITY OF CUPERTINO
FEE ESTIMATOR -BUILDING DIVISION
ADDRESS: 20376 Via Napoli DATE: 03/26/2012 REVIEWED BY: Sean
APN: 316-01-136 BP#: -VALUATION: $500
*PERMIT TYPE: Electrical Permit PLAN CHECK TYPE: Alteration /Addition / Repair
PRIMARY SFD or Duplex PENTAMATIOPERMITTYPEN 1REAP10
USE:
WORK Install a GFCI protected outlet in crawls ace.
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Recep/Switch/Outlets iBREMRECEP 1 # $44
TOTALS: $44.00
h
If cb. Pbm('h,rk Plnn,h. Plon CLeeA Elec. Plan Check FO.0hrs $0.00
bleed. I......il Fe": Mwnh. Po mit 1".U: Elec. Permit Fee: 1 SPERM/T
Other Ah"h. Imp, Other Plumb Insp. Lj Other Elec. Insp. 0.0 hrs $44.00
,16•,h.Imp, /hlv: Plmnh. bnp. Fe,r Clce. Iav,. I-ce:
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 rile prelimina information available and are only an estimate. Contact file De t or addn7 info.
FEE ITEMS (Fee Re.solulion 11-053 E(( 7/1/11) FEE QTY/FEE MISC ITEMS
Plan ('lyre/.: Fug:
.Supp/. PC F,•c
PME Plan Check: $0.00
Permit Far•:
Sup/pl. lnsp l-'ea
PME Unit Fee: $44.00
PME Permit Fee: $44.00
C'anstraclion Tax.
Administrative Fee: IADM/N $41.00
Work Without Permit? O Yes 0 No $0.00
Adruuced Planmin.V Fees:
Travel Documentation Fee: ITRA VDOC $44.00 A
Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item
131de Sids Commission Fee: IBCBSC $1.00
SUBTOTALS: $174.50 $0.00 TOTAL FEE: 1 $174.50
Revised: 1/19/2012
GENERAL PERMIT APPLICATION M E P
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO,CA 95014-3255 M I
sc
CUPERTINO (408)777-3228•FAX(408)777, 33 • buil ' cu ertino.a
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PLUMBING hilieLAMCAL _ CAL MISM IANEOUS
PROIECTAmmss �Zae� AFNY /I _ / .� I - LL
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OWNER NAME FHONE — E-MAIL
S Rn7ADDRESS ' 1 v CITY,STATE,IIP FAX
CONTACT NAME FHONE &MAD.
STREETADDRESS .CITY,STATE, ZIP FAX
❑OwNER ❑ OWNIA-BImDFA ❑ OWNERAGENT ❑ CONTRACTOR ❑CON TACTORAGENr ❑ ARCRITELT ❑FNGOIEEB ❑ DEVELOPER ❑ TENANT
CONTRACTOR NANM • r� LICENSE NUMBER I/Z5 "CFNSE TYPE O BUS.TIC Y
COMPANYNAME C E-MAIL -}�Q✓� FAX
TTIM3
61 -
ARCHITEMENOINEE.R NAME LICENSE NUMBUt BUS.LIC Y
COMPANY NAME EMAD. FAX
STREETADDRESS CRY,STATE,78 PHONE
USE OF $FDwOUPLEr ❑ MULTI.FAMO.Y .PROIFLTINWRDIANU ❑ YES PROJECT IN 13 YES IS THE BLDG AN ❑YES
BUILDING. ❑COMMERCIAL URBAN INTERFACE AREA NO FLOOD ZONE NO Eloam ROAD ❑NO—
DESCRIPTION
ODESCRIP ION OF WORK
i s \ �
V
TOTAL VALUATION: / RECEIVED BY:
By my signature be ,I certify ta each rite . I am The property owner or authorized agem m act as the property owner's behalf I have read this
application and the information I hav cortect, have read the Daeripticn of Work and verify it is accurate. I to comply with all applicable local
ordir mtcca aad stare laws relating to g on. I authorize representatives of Cupertino to enter the abry i;i;ai pro cry for inspection pu4poses.
Signature of AppliranVAgent- Date:
SIJrPNMrrAE INFORMATION REQUIRED OFFICE USE ONLY
W OVER-THE-COUNTER
6
❑ EXPRESS
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❑ STANDARD
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❑ LARGE
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❑ MAJOR
MEPMcrapp_2011.dac revised 06121111