12070150 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 1611 POPPY WAY CONTRACTOR:DELGADO PERMITNO: 12070150
CONS'T'RUCTION,INC. '
OWNER'S NA\TE: YOSI-IIKAWA SAM NI TRUSTEE 667 N FIRSTSI' DATE ISSUED:07/182012
O\VNIi PIIONE: 4088915855 SANdOSE,CA 95112 PIIONENO:'(408)998-8200
LICFNSED CO\I'RAC`fOR'S DECLARA'T'ION
BUILDING PERM1IIT INFO: BLDG r ELECT r PLUi\11Q r
License Class. 6
AIECII r RESIDENTIAL r COMMERCIAL r
Contractor
Date � Z
Iherehv;m train (I am lire J der the prvn'isiuns of Chnpter9 JOB DESCRIPTION:SERVICE UPGRADE T0200AMP5
(route ing wi m Scctian Of Division 3 of the Business& Professions '*SEE NOTES--
"to
• d ihn q licens n full force:rad effect.
herehv affirm under penalty of perjury one of Thr following two declarations:
I have and will maintain a certificate ol'consent to self insure for Worker's
Compensation,az provided for by Section 3700 of the Labor Code,for the
performance of the work for which this perntil is issued.
I have and will maintain Worker's Compensation Insurance,as provided for by
Sq.Ft Floor Area: Valuation:$1800
Section 3700 of the Labor Code,for the performance of Orae work for which this
permit is issued.
AP,N Number:36615038.00 Occupancy Type:
.U'I'LICAN'I'CP.IfI'I PIC,\'PION
I certify that I have read this application laid state that the above information is
correct.1 agree to comply with all city and county ordinances and state Imus relating
to building construction,and hereby authorize representatives ollhis city to ewer 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 accme against said City in consequence of the 1g0 DAYS FROM LAST CALLED INSPECTION.
granting of this permit. Additionally,the applicant understands and will comply
with all non point sour r go atims per the eni m Municipal Code,Section n q
9i18Issued
na2GJ Datew—•••�y-
>,
O :R-Ii1111.DEll DECLARATION RF:ROOFS:
All roofs shall be inspected prior to any roofing material being installed.If a roof is
ere :mlTirm That 1 am esrmpt from the Cmuraclor's License Law for one of installed without first obtaining an inspection,I agree to remove all new materials for
II olluwingtwo reasmms: � inspection.
I,as owner of the property,or nay employees with wages as their soli compensation,
will do the work,and the stmeture is not intended or offered for sale(Sec.7044, Signature of ApplicnC Date:
Business&Professions Code) _
1,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,13usiness&Professions Code). ALL ROOF COVERINGS TO BE CLASS"A"OR BFTTF,R
hereby affirm under penalty of perjury'one of the following three
declarations: IIA%ARDOUS MATERIALS DISCLOSURE
I have and will maintain a Certificate ol'Consent to self-insure for Worker's I have read the hazardous materials iegmrc oenls under Chapter 6.95 of the
Compensation,as provided for by Section 3700 of the Labor Code,for the California Ilealth&Safely Code.Sections 255M25533.and 25534. 1 will maintain
perfam ance of the work for which this permit is issued. compliance with the Cupertino Municipal Code:Chapter 9.12 and the Ilealth&
I have mid will maintain Worker's Compensation Insurance,as provided for by Safety Code.Section 25532(x)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
permit is issued. contaminants as defined by the BayArea Air�Qunlily Management District I will
I certify that tmaintain compliance with the Cupertino Jl unieipal'Code,Chapter 9.12 and the
the performance of the work for which this petit is issued.1 shall Ileallh&Safet � r ,Seelions 25505,25533,and 25534.
not employ any person in any manner so as to become subject to the Worker's
Compensation laws ofCalifomia. If,atter making this certificate of exemption,1 Owner 5at orizrdr 1: 2
become subject to the Worker's Compensation provisions of the Labor Code,I must Date:
forthwith comply with such provisions Or this permit shall be deemed revoked.
CONS'I'R11C1'If1,N I,ENIIING ACENCI'
,\PI'LICAN'I'CI?It'1'IPIC,\TION reby aB' mm there is a construction leading 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 corny ordinances and state laws relating Lender's Name
to building construction,and hereby authorize representatives ollhis 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,judgmenis,
costs,and expenses which may accrue against said City in consequence of the
grinning of this permit.Additionally,the applicant understands and will comply ARC11ITE .1"S DECLARATION
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 Professionals
Signature Date
CITY OF CUPERTINO
FEE ESTIMATOR - BUILDING DIVISION
ADDRESS: 1641 poppy way DATE: 0711812012 REVIEWED BY: bobs.
ANN: BP#: 'VALUATION: $1,800
*PERMIT TYPE: Electrical Permit PLAN CIIECK TYPE: Alteration /Addition / Repair
PRIMARY PENTAMATION
USE: SFD or Duplex PERMITTYPE: 1REAP
WORT: service upgrade to 200am s.
SCOPE
APPLIANCE/EQUIP TYPE FEE ID Q'I'l' UNITS BP FEES
Services 1ERT<200 200 Amps $45
TOTALS: $45.00
Xlech. Plan Check Phunh. Plan Check Elec. Plan Check 0.0 hrs $0.00
Mech. Permit Fee: Plumh. Permit Fee: Elec. Permit Fee: IEPERMIT
Other•,Vech.Insp. Other Plumb lip. Ll I Other Elec. Insp. LLO hrs $45.00
,b/ach.lisp. Fee: Plumb. hecp.Fez: Elec.hip. Fee:
NOTE: This estimate sloes not include jecv due to other Departments(i.e. Planning, Public Narks, Fire,Sanitary Setter District,School
District. etc.). These feev are based on the relintinaninformation available and are onh•an estintnte Contact the Dept for addit7 info,
FEE ITEMS (Fee Resolution 11-053 Elf. 71111!/ FEE QTY/FEE MISC ITEMS
Plan Check Fee:
Suppl. PC Fee
PMH Plan Check: $0.00
Permit Fee:
.Sttppl. Insp Fee
PMC Unit Fee: $45.00
PME Permit Fee: $45.00
Consrrmciion Tax
Administrative Fee: /ADMIN $42.00
Work Without Permit? O Yes 0 No $0.00
Advanced Planning Fees.-
Travel
ees:Travel Documentation Fee: 1TRAVDOC $45.00
A
Strong Motion Fee: IBSFlS,tIICR $0.50 Select an Administrative Item
Bide Sids Commission Fee: IBCBSC $1.00
SUBTOTALS: $178.50 $0.00 TOTAL FEE: 1 $178.50
Revised: 07/01/2012
l of SO
GENERAL PERMIT APPLICATION I r l E P
COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 950143255 w w ' /�
v\
CUPERTINO (408)777-3228 • FAX(408)777-3333• buildina(c)cuoerMino.ora
❑PLUMBIN( O GG ❑MECFLANICAL ❑ELECTRICAL ❑MfISCELLA.AIEOUS
\
FRO=ADDRESS 1 �0. APN,y / c 15' �Z
OWNER NAME l t PNO E- J
vt^ 0S w o'
STREET ADDRESS '/ I I STATE_ q,O( FAX
�O W'L �fl PB /� o
COMACLN I'S'SA`'t art"'C��A �y •_J` .Ca
STREET ADD
❑OWNER ❑ OWNER-Btm.DER ❑ ONMRAGENr CONTRACTOR ❑CONTMCT9R AGFNL ❑ CHTTECT ❑ENGNEER ❑ DEVELOPERS ❑ TENANT
CONTRACTOR A.�4E (1 I ^ o LICENE � LICENSE T?E BUS.LIC N
COMPANY yvUfr�JS� E MAIL FAX, C;t j ZO O
SIR..s'R ADD c S ^ A f` '��— SY� r— I CITY,S�,ATE Z[P SCf I PHONE^,r
A.RCH77EC T/ENODQD R NAME LICENSE NUMBS I BUS.LIC A
COMPANY NAME' E-MAB. FAX
STREET ADDRESS / Cfi Y,STATE.7 I PHONE
USE OF EISM.DUPLEX ❑ MULT,-FAMILY I PROJECT WJI.DLWD O YES PROJECT IN ❑ YES is THEBIDGAN ❑ YES
SIMLONG: COMD.ERt URBAN NTEAFACE AAE> NO FIDOD ZONE 0 N EICJiIFR HOME: CI NO
DESCRnMON OF WORX A s
TOTAL VALUATION: / I RECEIVED BY: ICJ/
By my sig:tature below,I cerdPy W each of the following: I am the propery owner r authariud cot to-ton dte pmpeny owner's behalf 1 have read;his
application and the lot- nation I have provide ' oTect. I have toad the an of Work and verity it is accurate. I agree m comply wilt all applicable local
ordinances and sate Iaws relating m 6ui ',.g co ,:cdon. I antheri' o_entatives of Cupertino to enter the above
2-iden' ed pro etty for inspection pu:posrs.
Signanne ofApplicandAgrnc Date: �I 0 C
SUPPL . EENT ON REQUIRED OFFIc use ONLY
Er�v OVER-THE-COUNTER
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❑ EXPRESS
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❑ STANDARD
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❑ MAJOR
iLIEP�Lfua4pp_3011.doc revised 06/31/71