12080246 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 20635 NANCY CI' CONI'RACI'OR:WILLOW GLEN ELECTRIC PERMITNO: 12080246
INC
OWNFIVSNAME: SEEJOPYLAPPAN 1085 WARREN AVE DATE ISSUED:08232012
OWNER'S PHONE: 9194126762 SAN JOSE.CA 95125 PHONE;NO:(4081289-9725
❑ LICENSED CON"IRACI'OR'S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT r PLUMB r
License Class C,10 Lie.q 551918
I ,,� NECII r RESIDENTIAL r COMMERCIAL
Commeor W)11rn./ G le,„ G/:3-VW(-Dale a3 bz
herellyaflirnt[hittlain licensed muter the prmisiunsof Chapter9 JOB DESCRIPTION:SERVICE UPGRADE TO 200 AMPS
(coil] tci(h Section 7000)of Division 3 of the Business S Professions
Cute and that nnlicense is in full force and effect.
herebyfir
affirm under penalty of perjury ane of the following t"n declarations:
I have and will maintain a certificate of consent[o 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:$3200
1 have and will maintain Worker's Compensation Insurance,as provided for by
Section 3700 of the Labor Code,for the perfomtance of due work for which this
permit is issued. Al;N Number:35915025.00 Occupancy?-3 pe:
A I'1'LICAN'I'CIiR'I'I FICA"PION
I certify that I have read this application and state that the above infommlion is
corecL lagree to comply with all city and county ordinances and state Imes re
lming 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
indcmnil}•and keep harmless the City of Cupertino against liabilities,judgments, 180 DAYS FROM LAST CALLED INSPECTION.
costs•and expenses which may accrue against said City in consequence of the
granting of this permit. Additionally
.the applicant understands and will comply
with all non-p int urge regulations per the Cupertino Municipal Code,Sectiat Issued bv: �- Date:
9.18. O
Signature Date C�
RE-ROOFS:
❑ OWNER-BUILDER DECLARATION All roofs shall be inspected prior to any roofing material being installed.If a roof is
installed withoa first obtaining an inspection,I agree to remove all new materials for
hereby affirm[hart 1:un exempt from the Contractor's License Lae'for one of inspection. '
the fallowing nvo reasons:
1,as owner of the property,or my employees with wages as their sole compensation, Signature of Applicant! Date:
will do the work,and the stricture is not intended or offered for sale(Sec.7044,
Business- Professions Code)
1,as owner of the property,tan exclusively contracting with licensed contractors to ALL ROOF COVERINGS TO RE CLASS"A"OR BIS1"1'ER
construct the project(Sec.7044.13usiness S Professions Code).
1 hereby affirm under penalty of perjury one of the following three IIA%ARDOUSMA'I'ERL\LS DISCLOSURE
declarations: I have read the hazardous materials requirements under Chapter 6.95 of the
I have and will maintain a Certificate ofConsenl to self-insure far Worker's California Ilealth S Safer'Code Sections 25505,25533,and 25534. 1 will maintain
Compensation,as provided for by Section 3700 of the labor Cade,for the compliance"fill the Cupertino Municipal Code.Chapter 9.12 and the Health S
performance of the work for which this permit is issued. Safety Coda Section 25532(a)should I store or handle hazatrdous material.
I 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"ark for which this contaminants as defined by the Bay Area Air Quality Management District I will
permit is issued. maintain compliance with the Cuperli no dl mnici pal Code,Chapter 9.12 and the
Health S Safetv Code,Sections 25505,25533.and 25534.
I certify that in the performance of die work for which this pemtit is issued,I shall
not employ any person in any manner so as to become subject to the Worker's O%71e oq r uulhuri
Compensation laws of Cali fornia. It...after nnkingthis certificate ofexentption,I '/1VJ)Id11�i, ��/tj Date: J
become subject to the Worker's Contpensmion Provisions of the Labor Code,I nmst
forthwith comply with such provisions or this permit shall be deemed revoked. CONS'I'Kl1CI'ION LENDING AGENCY
I hereby affimn that there is a construction lending agency for theperfomnance of work's
A PPLICAN9'CE:RTI FICATION for which this permit is issued(Sec.3097,Civ C.)
I certify that I have read this application and state that the above infomnation is Lender's Name
correct. I agree to comply with all city and county ordinances mid state Inas relating
10 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 hamnless the City of Cupertino against liabilities,judgments,
costs,and expenses which may:¢crus against said Cit•in consequence of the ARCI I1TIiCI"S DI?CL.\R.\'PION
granting of this permit.Additionally,the applicant undcr[ands and will comply I understand any plans shall be used as public records.
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18. Licensed Professional
Signature Date
I/
j $ vZ`-((.,c
GENERAL PERMIT APPLICATION M E P
COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 MIS C
CUPER1O (408)777-3228• FAX(408)777-3333•building(acuoertino.orG
PLUMBING DIVIECIIANICAL ELECTRICAL MISCELLANEOUS
PROJECT ADDRESS 2Oci - 1*'Jq �C Co-,F+ �P '3� i ( -D — c> Z
OWNER NAMESC 0 1 (-(/e X G1 1 I CI Q VI ��91 1 -41a- b"I b� E'",,"
STREET ADDRESS 7O 35 i `/4,iC C+, CITY.STATE,ZIP % CfJI c15J/ PAIL
CONTACT NAME /./I PHONE E-MAIL
STREETADDRESS 10 Q S WGC � . CnY.STATR ZIPS--{ Q1- ` a 0 FA%
❑OWNER ❑ OWNER41U11DER ❑OWNERA@fT A CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT
CONTRACTOR NAME LICENSE NUMBER LICENSE TYPE BUS.LICLICENSE
Lorlole 6 Co
coMmnrn•NAMe E-MAIL FAX 406-(o5a9'O J'/
LLow CnLF. _ cL�.CT2.IC� a � Lc.�' c lc•C
STREET TIM,
DDRESS CITY'.STATE,ZIP PHONE
orr
ARL'FIITECTIENGINEER NAME LICENSE NUMBER BUS,LIC Y
COMPANY NAME E-MAIL FA.Y
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF .-DUPLEX ❑ MIILTr-FAMIRY PROTECTENWILDLAND ❑ YROMCIN YES YES
UBAN INTERFACE ARBA NO FLOOD ZONE PkNU JIZNO❑COMMERCAL
DESCRIPTION OF WORK 2 -` 'l^ Q nz ( v r
Aok
TOTALVALUAMON: 1.3 2✓]V RECEIVED BY:
By my sigrlamre below,I mnify m each of the following: 1 am the property owncr or authorind agent to act on the property owner's behalf. I have read this
application and the information I have ovis correct. I have read Areption of Wart andverify it u accurate. I egret to comply with all applicable local
ordinances and sole laws relating t cTo•�n(s�tryc7ro rve rtpr n of Cupertino to enter the above-i enti�/{opeIT),for inspection purposes.
SignatureafApplicvtVAgenl: ons Dote: sla I z
SUPPLEMENTAL INFORMATION REQUIRED �OF�FICE.USE ONLY
u CI (1V P.R-TIIF.C(IUMPR
6
y� ❑ EXPRESS
U
rr ❑ STANDARD
V
2 ❑ LARGE
E
❑ MAJOR
AIEPMiscApp-101 Ldw revised 06/11/11
CITY OF CUPERTINO
FEE ESTIMATOR - BUILDING DIVISION
ADDRESS: 20635 nancy ct. DATE: 08/23/2012 REVIEWED BY: bobs.
ARN: BP#: 'VALUATION: $3,200
*PERMIT TYPE: Electrical Permit PLAN CHECK TYPE: Alteration /Addition / Repair
PRIMARY PENTAMATION
USE: SFD or Duplex PER1n• 'n,PE: 1 REAP i
WORT: service upgrade to 200 amps.
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Services 1ERT<200 200 Amps $45
TOTA LS: $45.00
b/ech. Plan Check Phunh. Plan Check Elec. Plan Check 0.0 1 hrs $0.00
Mech.Permit Fee: Plumb. Pcrmir Fee: Elec. Permit Fee: IEPF-RMIT
Other Mech.Insp. Other Plumb Imp. Other Elec. Insp. 0.0 hrs $45.00
Meth.Insp. Fee: Plumb, bt.sp.Fee: Elce.Insp.Fee:
NOTE: This eviinmte does not inchalejees due to other Departments(i.e. Planting, Public Works, Fire,Sanitary Sewer District,School
District,etc.). These feev are based on the prelintinan•information available and are onh,an estimate. Contact the Dept for arra 7 info.
FEE ITEMS (Fee Resolution /1-053 /ill. 71111/) FEE QTY/FEE MISC ITEMS
Plan Check Fee:
Suppl. PC Fee
PME Plan Check: $0.00
Permit Fee:
Supp/. lnsp Fee
PME Unit Fee: $45.00
PME Permit Fee: $45.00
Consnroction Tac:
Administrative Fee: /ADMIN $42.00
Work Without Permit? O Yes Q No $0.00
Advtntced Planning Fees:
Travel Documentation Fee: ITRAVDOC $45.00 A
Shone Motion Fee: IBSEISbnCR $0.50 Select an Administrative Item
Bldg Sids Commission Fee: IBCBSC $1.00
SUBToTALS: $178.50 $0.00 TOTAL FEE: $178.50
Revised: 07/01/2012
Building Department
City,Of Cupertino
10300 Torre Avenue
C U PE RTI N O `Telephone: 408-777-3228
Fax: 408-777-3333
CONTRACTOR / SUBCONTRACTOR.LIST
JOBADDRESS: X005 /NJarlt C+ - PERMIT#
OWNER'S NAME: J P I n ar PHONE# Q08—.
GENERAL CONTRACTOR: BUSINESS LICENSE#
ADDRESS: CITY/ZIPCODEi
*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 SUBCONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO
BUSINESS LICENSE.
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
Owner/Contractor Signature Date