12050128 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: NFOOTIULL&280 CONTRACTORm4'140 TO 3E PERMIT NO: 12050128
ED
OWNER'SNA111E: CALTRANS W� r .I U,ke� DATE: ISSUED:05/152012
OWNER'S PHONE.: PIIONF.NO:
❑ LICENSED CON'TRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL CONIMERCIA1.
11
License Class L L 10 Lie,4 9 5n1 13 REPLACE 50 AMP BREAKER WITH A 60 AMP BREAKER
Contractor JCjl.} W4-)-K-6Z Date 0 S—I S— t Z
I hereby affirm that I am licensed under the provisions of Chapter 9
(commencing with Section 7000)of Division 3 of the Business&Professions
Cade and that my license is in full force and effect.
I hereby affirm under penally of perjury one of the following two declarations:
1 have and will maintain a certificate of consent to set Finsure for Worker's
Compensation,as provided for by Section 3700 of the Labor Code,for the
performance of the work for whichthis permit is issued. Sq.FI Floor Area: Valualion:$100
1 have and will maintain Worker's Compensation Insurance,as provided for by
Section 3700 of the labor Code,for 6e performance of the work for w ich thi
APN Number:32601.CALTRAN Occupancy"Typr.
permit is issued,
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED
correct.I agree to comply with all city and county ordinances and state laws relating WITHIN 180 DAYS OF PERMIT ISSUANCE OR
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save 180 DAY LAST CALLED INSPEC IO
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the '
granting of this permit. Additionally,the applicant understands and will comply Issued by: Date:
with all nun-point source regulations per the Cupertino Municipal Code,Section
9.18.
RE:ROOFS:
Signature - Date nS- 1 S'-1 Z— All roofs shall be inspected prior to any roofing material bong installed_If a roof is
installed without first obtaining an inspection.I agree to remove all new materials for
inspection.
❑ OWNER-BIIILDE:R DECLARATION
1 hereby affirm that I em exempt from the Contractor's License Law for one of Signature of Applicant: Date:
the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
I,as owner of the property,or my employees with wages as their sole comp:nsation,
will do the work,and the structure is not intended or offered for sale(Sec.7044,
Business&Professions Code)
I,as owner of the property,am exclusively contracting with licensed contractors to IL$"LARDOUS MATERIALS DISCLOSURE:
construct the project(Sec.7041,Business&Professions Code). 1 have read the hazardous materials requirements under Chapter 6.95 of the
California Ilealth&Safely Code,Sections 25505,25533,and 25534. 1 will
1 hereby affirm under penaly 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 1 store or handle hazardous
I have and will maintain a Ceniftcale 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
performance of the work for whichthis 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 lleallh&Safety Code.Sections 25505,25533,an 5534.
Section 3700 of the Labor Code,for 6e performance of the work for which this
Owner or authorized age
permit is issucd. nt: Date:
I cenify,that in the performance of the work for which this 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,after making this certificate of exemption,I CONSTRUCTION LENDING AGF.NCV
become subject to the Worker's Compensation provisions of the Labor Code,1 must I hereby aff tan that there is a construction lending agency for the performance of
forthwith comply with such provisions or this permit shall be deemed revoked. w'ork'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 stale 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 ARCIIITE:(T'S DECLARATION
and keep harmless the City of Cupertino against liabilities,judgments,
costs,mid expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records.
granting 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
CITY OF CUPERTINO
FEE ESTIMATOR- BUILDING DIVISION
ADDRESS: Foothill Express Wy&280 DATE: 05/11/2012 REVIEWED BY: Sean
APN: BPN: 'VALUATION: $100
*PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration /Addition / Repair
PRIMARY Commercial Building PENTAMATION 10EAP7
USE: PERMIT TYPE:
WORK Re lace 50 amp breaker with a 60 amp breaker.
SCOPE
Mech. Plan Cherk Plumb. Plan Check Elec. Plan Cheek 1 0.0 hrs $0.00
meah. Prrurir Fee- Phunh. Permdr Fee: Elec. Permit Fee: IEPERAIIT
Other,llech. Ince. Other Plumb In.sp. Other Elec. Insp. 0.0 hrs $44.00
.1 Jc(h. hr,I,. Pcc: Plumb. In¢. Fee: tile,-, Imp. Fre.
NOTE: This'estimate does not include fees due to other Departments(Le. Planning, Public Works, Fire,Sanitary Sewer District,School
District,etc). Thesefees are based on the prelimina information ayailable and are only an estimate Contact the Dept for adr1n7 info.
FEE ITEMS(Fee Resohdion ll-053 1if.' 71111 U FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 0 1 # Electrical
Suppl. PC Fee: 0 Reg. 0 OT 0.0 hrs $0.00 $0.00 IBREMMISC I Conductors
PME Plan Check: $0.00
Permit Fee: Hourly Only? 0Yes 0 No $0.00
Suppl. lnsp. Fee:O Reg. 0 OT 0.0 hrs $0.00
PME Unit Fee: $0.00
PME Permit Fee: $44.00
C'unso ue ion l its:
Administrative Fee: (ADMIN $41.00 0
Work Without Permit? 0 Yes 0 No $0.00 0
Advanced Planning Fee: $0.00 0 hours Inspections 0
Travel Documentation Fee: ITRAVDOC $44.00 $130.00 ISTINSP Inspection, Hourly
Strong Motion Fee: IBSEISMICO $0.50 Select an Administrative Item
Olde Sids Commission Fee: IBCBSC $1.00
SUBTOTALS: $130.50 $130.00 TOTAL FEE: $260.50
Revised: 04/01/2012
CITY OF CUPERTINO
7 ITEMS OF 7 PERMIT RECEIPT OPERATOR: SylviaM
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . . 32601.CALTRAN
DATE ISSUED. . . . -. . . : 05/15/2012
RECEIPT #. . . . . . . . . : BS000016833
REFERENCE ID # . . . : 12050128
SITE ADDRESS . . . . . : N FOOTHILL & 280
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : CALTRANS
ADDRESS . . . . . . . . . . : LOCAL ASSISTANCE
CITY/STATE/ZIP . . . : OAKLAND, CA 94623
RECEIVED FROM . . . . : WALKER CELLULAR
CONTRACTOR . . . . . . . : TBD - TO BE DETERMINED LIC # 00.096
COMPANY . . . . . . . . . . : TBD - TO BE DETERMINED
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . .
TELEPHONE . . . . . . . . :
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 100.00 1.00 0 . 00 1 . 00 0 . 00
1BSEISMICO VALUATION 100 .00 0 .50 0 . 00 0 .50 .0. 00
1BUSLIC FLAT RATE 1 .00 119. 00 0. 00 119.00 0. 00
1EPERMITFE FLAT RATE 1.00 44 . 00 0.00 44 .00 0.00
1STINSP UNITS 1.00 130.00 0.00 130 .00 0 .00
1TRAVDOC FLAT RATE 1.00 44 .00 0.00 44 .00 0 .00
---------- ---------- ---------- ----------
TOTAL PERMIT 379 .50 0 . 00 379. 50 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CHECK 379.50 1339
---------------
TOTAL RECEIPT 379.50
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- ---- ----------------------------
304
------- -------- -
304 ROUGH ELECTRICAL 505 FINAL ELECTRICAL
GENERAL PERMIT APPLICATION M E P
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DNISION
10300 TORRE AVENUE•'CUPERTINO, CA 95014-3255 M I
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CUPERTINO (408)777-3228•FAX(408)•777-3333•buildina(EcDta
cuoertino.o
❑PLUNBING ❑MECHANICAL ELECTRICAL ONESCQ,(,gNE�o
PROIFIT ADDRESS -ODILL &XPY I – zw APNa
OWNER NAME T ,t^ oD I PHONE E-MAIL
STREETADDRESS 1 '•1 n CITY. STATE.ZIP FAX
CONTACT NAME I G •. 0- C T PHONE •�.-y79-I(17 E-MAIL>7
STREET ADDRESS I(]CC 6 r•I-SAI. (1 t , ,STATE.ZIP C nN! ^ 64 11 Ll � FAX
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❑OWNER ❑ OWNER-SUm.nm . ❑ OWNER AGENT• CONTNACrOR, ❑CONTRALIOR AGENT ❑ AaamT T ❑ENtaNEER ❑ nEvzLoPEIt ❑ TFIUHT
CONTRACTOR NAA E �0sti- W LICENSE NUAaER 9 S LI/I LICENSE TYPEGZ2
0 EUS.GC a
CONUANY NAME U (ALrt.n C–(; LULfL INC— ENAIL
FAX
STREETADDRESS q J , 0-165 som A 4ZD CITY.STA $ZIP L I Nc OL✓ 6PPHONE
9/6-717- 36
ARCHITECTIENIGINEER NAME LI@NSE NUMBER EDs.LIC p
COMPANY NAMEE-MAIL FAX
STREET ADDRESS 'CITY,STATE.ZIP PHONE
USE OF ❑SFO wDUPIEY ❑ MUI.TFFAMRY. -PROIERIt WIDLWp ❑ YE4PROIECEN ❑YES DTF@ELDG AN [3 YES
EUI LINO: MMEJROAL :URBAN INTERFACE AREA NO FLOOD ZONE NO ETCHLElt HOME? 3rNO
DESCRIPTION OF WORK
60 MP
TOTAL VALUATION: RECEIVED RY:
By my signature below,I certify to each of the followmq,i am the property owner aT aothorimd agent to act on the property owner's behalf I have read this
application and the khrmation I have provided is emrect)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 building wostraction.,l autherhte representatives of Cupertino to enter the above4dentified property for inspection puhposes.
Signature:ofApplieandAgent Date:
LEMENTAL INFORMATION REQUTR Fn OFFICE USE ONLY
r OVER-THE-COUNTER
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F ❑ WRESS -
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u ❑ STANDARD
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❑ LARGE
❑ MAJOR
.. A-HPM scApp_2011.doc revised 06/21/11