12100078 CITY OF CUPERTINO BUILDING PERMIT
BIJILDINGADDRESS: 10587RANDYLN CON'RACI'OR:3P89+g4.49 PERMITNO: 12100078
DET£Rfi1tNED
OWNER'S NA101r: EASTWOOD DENIS AI AND KAY S, ' DATE ISSUED: 10/10/2012
OWNER'S PHONE: 4082555946 PHONE NO:
/ JORDF,SCRIPPION: RESIDENTIAL COMMEIRC1A1.
11
❑' LICENSED COMTH,hCI'OR'S DECLARATION
License Class C;) Lic.4 � 2CfJ-71 1� ELECTRICAL SERVICE UPGRADE 200 AMP
Contractor Date
hereby uffirm that 1 am licensed under the provisions of Chapter 9
(commencing with Section 7000)of Division 3 of the Business&Professions
Code and that my license is in full force and effect.
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 3700 of the Labor Code,for the
performance of the work for which this permit is issued. Sq.Et Floor Area: Valuation:$2200
1 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
AI'N Number:31602051.00 Occupanry'1'ypc
permit is issued.
APPLICANT CER'Fl FICATION
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 ordin:mces aid state laws relating WITHIN 180 DAYS OF PERMIT ISSUANCE OR
to building construction,and hereby authorize representatives of this city to enter i
upon the above mentioned property for inspection purposes. (We)agree to save 180 DAY FROM LAST CALLED INSPECTION.
indemnify and keep harmless the City of Cupertino against l iabilities,judgments, /
costs,and expenses which may accrue against said City in consequence of the L
grantingof this permit. Additionally,theapplicant understands and evil]comply Issued by: /t .f/li Date:
with all non-point source rem ion aha Cupertino Municipal Code,Section
9.18. v
�� RE-ROOFS:
Signature Doe / �1.7 All roofs shall be inspected prior to any roofing material being installed.If a roof is
installed without first obtaining an inspection,I agree to remove all new materials for
t inspection.
❑ OWNF,R-BUILDER DECLARATION
Signature of ApplicanC Date:
hereby affirm(hit( I am exempt tram the Coniniclnr's license hoe'for one of
the following two reasons: ALL ROOF COVERINGS TO RE CLASS"A"OR BE'PI'ER
I,as ownerof 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)
1,as owner of the property,am exclusively contracting with licensed contractors to IIA'LARDOUS DLATERIAIS DISCLOSURE
construct the project(Sec.7044,Business&Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the
California Ilealth&Safety Code,Sections 25505.25533.and 25534. [will
1 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&Safety Code,Section 25532(x)should 1 store or handle hazardous
I have and will maintain a Certificate 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 1
performance of the work for which this permit is issued. will maintain compliance wish the Cupertino\I unici pal Code,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sections 2 50 .2 533?and 25531.
Section 3700 of lire Labor Code,for the performance of the work for which this /O—/0— z
Owner or authorized agent: Dale:
permit is issued.
I certify that in the performance of die 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 AGENCY
become subject to the Worker's Compensation provisions of the Labor Code,1 must I hereby affirm that there is a construction lending agency for the performance 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.)
Lender's Name
APPLICANT CF,R'1'I1;IC 'I'I0N Lender's Address
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 lays 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
indemnify and keep hmmless the City of Cupertino against liabilities,judgments, ARCHITECT'S DECLARATION
costs,and expenses which may accrue against said City in consequence of the [understand my plans shall be used as public records.
granting of this permit.Additionally,the applica t 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: 10587 randy In DATE: REVIEWED BY: larrys
APN: BP#: VALUATION: $2,200
"PERNIIT TN'PE: Electrical Permit PLAN CHECK TYPE: Alteration/Addition / Repair
PRIMARY SFD Or Duplex PENTAi•tATION 1REAP2
USE: PERMITTYPE: At
WORK
SCOPE
APPLIANCE EQUIP TYPE FEE ID QTY UNITS BP FEES
Services 1ERT<200 200 Amps $45
TOTA LS: $45.00
Much. Plan Check Plumb. flan C'luxk Elec. Plan Check 0.0 1 hrs $0.00
Alech. Permit Fee: Phonh. Permit Fee: Elec. Permit Fee: IEPERAHT
Other Afech. Insp. Other Plumb lne7a Other Elec. Insp. 0.0 hrs $45.00
E37-
Wech,hip. Fee: Plumb. hisp. Fee: Elec. Insp.Fee:
NOTE: This estimate does not inc/udejees due to other Departments(i.e. Planning, Public II'orks, Fire,Sanitary Sewer District,School
District,etc. . These feev are based an the prelitninan information available and are onh,an estimate. Contact the Delitfor athbt'I info.
FEE ITEMS (Fee Resohi ion 11-053 Elf. U7/I21 FEE QTY/FEE MISC ITEMS
Plan Check Fee:
Snppl. PC Fee
PME Plan Check: $0.00
Permit Fee:
Smppl. hrsp Fee
PME Unit Fee: $45.00
PME Permit Fee: $45.00
Construction Tar:
Administrative Fee: IAU,t4LV $42.00
Work Without Permit? O Yes Q No $0.00
Advanced Planning Fees:
Travel Documentation Fee: ITRdVDOC $45.00
i
Strong Motion Fee: IBSF-ISHICR $0.50 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $1.00
SUBTOTALS: $178.50 $0.00 TOTAL FEE: $178.50
Revised: 10/01/2012
GENERAL PERMIT APPLICATION M E P
C COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION
TORRE AVENUE • CUPERTINO, CA 950143255
(408) \n\ w w I
CUPERTINO (408)777-3228• FAX(408)7773lG�
333• buildinGct:Derino.orD '\v/I
❑2LLMBA1Ci ❑MECHANICAL ELECTRICAL ❑MISCELLAENEOUS
PROT-Cf ADDRESS R414119Y Z yE I APNX 3i' ^ ()G_ Os l
OWNERNAME D� ` , OoA PHONE O _ 5 -MAR
STREETADDRESS CRY, STATE ZIP I FAX
CONTACT NAME/�
STREE7.U*DRESSI72 S �1 CCJJ 1/� CITY.STATE ZIP
❑ OWNER ❑ OW - -BU'D.DE]t ❑ OWNER AGENT r-�CONIAACTOR ❑CONTMCTOR AGENT ❑ ARCFTECf_•❑/ENGIN= ❑ DEVELOPZR ❑ i1 N 7
CONTRACTOR NAME / / ( n 0/,' /7�� LICENSE NUMBER 7�O_ / LLTS-TYPE,O BUS.LCX
COMPANY NAME `�60 S CL/76/ f v'S/� E MAIL �J /� FAX �.
STREET ADDRESS ILZ S LO �J� CITY.STAATTE.ZIP ZZIE 10�/ � PHONE
ARCHREC7/ENGA'EEE NAME /5 LICENSE NUMBER U BUS.LIC X
COMPANYNAME' I E-MAIL FAX
STREET ADDRESS CIN.STATE,ZIP PHONE
USE OF O SFD a DUPLEX ❑ MULTI-FAMRY PROTECT 91 WT DLATD O YES PROTECT IN ❑YES I IS THE BLDG AN ElYES
BUR-DING: tX1M mkt. URBAN INTERFACE wRFA NO FLOOD ZONE ❑NO /EICHL-R HoM ❑NO
DESCRIPTION OF WORK42 7,90A,
TOTAL VALUATION / D I RECEIVED BY: �_
By my signet/re bel w,ILe_erdty to each of;he;ollowing: I am:he propc y owner or autharized agent to act on the property owner's behalf I have mad dvs
application aid the info..m:adon I have provided is cormCL I have;rad the Description of Work and verify it is accurate. I agree:o comply with all applicable local
ordinances and sate laws mlating mbuil 'r 0 Son. I authorize representatives of Cuaeino to enter the above-identified propccl for insnecion pulloses.
Signenit of Apolicant/Agmt: Date:
SUPPLEMENTAL INFORMATION REQUIRED OFFICE USE ONLY
❑ OVER-THE-COUNTER
❑ EXPRESS
U
❑ STANDARD
U
Z ❑ LARGE
J
❑ MAJOR
MEP.LIac9pp_?011.doc revised 06121/11
CITYOF cuPElz•rINo I3unLnlNc PERilt•u-r
DING ADDRI?SS: 937 BLAZINGWOOD AVE CONTRACT OIt:A&li HFA'f INCi PERMITSO: 12100061
o\\:NISK'sN,wns: noltcenti'n:KKYK,wociKOLYra 770 CI sr Dn-n; ISSUED: 10/091,012
OWNER'S PlION6: 4082551295 SAN•.IOSE,CA 9511) PI IONS NO:(408)279.07222
❑ 1,107NSIA)C ON-1,1tACfo It's DECLARA'T'ION
BUILDING 1'ERAII'P INFO: BLDG r ELEC'I'r I111UAl13 r
License Class—OL-7-0 Z
I.ic.fl {/ ��[ (
(] MECIIr It ESI UENTIALr COAI\IERCL\Lr
Contractor Ak� Date_!D=(
I hercbr affirm l t l am lia•nsed under the provisions of Cha plea') •JOB DESCRIPTION: REMOVEAND RIT1,NCE FURNACE,ADD A/C UNIT220
(com mmncin,with Section 7000)of Ili,inion 3 nl'thr Busi nes.,& Professions VOI:I'
CIRCUIT AND MAIN'T'AIN 3 1'001'SETBACK
Cud'and than my license is in full furec:nd effect.
I hereby affirm under penally of perjury one of(he fullusviug mo declarations:
I have and will maintain a certificate of consent to self-insure Iia 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.
I have and will maintain Worker's Compensation Insurance,as provided for by
Section 3700 of the Labor Code,for the perlonnanee of the work for which this Sq. FI Flool-Area: Valuation:$13000
permit is issued.
APPLICANT CFI4 FIFICA'1ION APN Number:36920018.00 Occupanep'1)pe:
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,road hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save PERMIT EXPIRES IF WORK IS NOTSTARTED
indemnify and keep harmless the City ol 'Cupertinm against I abi litics.judgments.
costs,led expenses Which may acerae against said City in consequence oflhe WITHIN 180 DAYS OF PERMIT ISSUANCE OR
granting oflhis permit. Additionally,tine applicant understands and still comply 180 DAYS FROM LASTCALLED INSPECTION.with all non-point source regulations per the Cupertino Municipal Code,Section
9.18.
Sinature
g ate /B __� Issued by: L �/ l✓ RTI/ Date:
❑ (1\YNI?K-141111-D I'.It I)ISCL:Ut,\'PION
RE ROOFS:
1 hereb, affirm[hal I am exempt front the Contractor's Licenec Law fur one of All roofs shall be inspected prior to any roofing material being installed.11'a roof is
the following nso reasons: installed without first obtaining an inspection.I agree to remove all nee•materials for
h as owner of the property,or my employees Willi wages as their sole compensation• inspection.
will do the work,and the structure is not intended or ol7cred for sale(Sec.704,1,
Business R Professions Code) Signature of Applicant: Dale:
L as owner ofllte property,not exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business C Professions Code), ALL ROUP CONTRINGS TO Iii?CLASS"A"OR BE'fl'FR
I herchy affirm under penally of perjure tine of the fullnwing three
'cclaaiums:
I have and will maintain a Certificate of Consent to self-insure for Worker's I IAZA R DOtIS.MATEAUALS DISCLOSURE
Compensation,as provided for by Section 3700 of the Labor Code,for the I hart read the hazardous materials requirements under Chapter 6.95 of the
performance oi'the work for which this permit is issued. California Health&Safety Code.Sections 25505,25533,and 25534. 1 will maintain
I have and will maintain Worker's Compensation Insurance,as provided for be compliance s$ilh the Cupertino Municipal Code,Chapter 9.12 and[he Health&
Section 3700 of the Labor Code,for the performance of the work for which this Safely Cuda Section 25532(a)should 1 store or handle hazardous material.
Additionally,should 1 tar equipment or devices which emit hazard tins:or
permit is issued. contaminants as(fertile(]by the Ifay Area Air Quality\I:nagenu•nt District I sill
I certify that in the perlonnanec ol'Ihe work for which this permit is issued,I shall maintain compliance with the Coperlimu Nlunicipal Code,Chapter 9.12 and the
not employ any person in aur manner so as to become subject it,the]Yorker's I Icalth&Safe)'Code Sections 25505,25533.and 25534.
Compensation lases of California. If after making this certificate of exemption.I
become subject to the Worker's Compensation provisions ofthe labor Code,I nest Che - nr nnlhtirized ng *e
Ibrthwiih comply with such provisions or this permit shall be doomed revoked.
A PPLIC\NT CER IIFIC TION CONSTRI1C110N LENDING ACENCY
I certify that I have read this application and Slane that the above information is I hereby it that there is a construction lending agency lirr the perfor niece ol'work's
correct.I agree to comply with all city and county ordinances and state laws relating for which this permit is issued(Sec.3097,Civ C.)
to building construction,and hereby authorize representatives of this city to ctucr Lender's N:une
upon the above mentioned property for inspection purposes.(We)agree to s:n'e
indenmify and keep harmless the City of Cupertino against liabilities.judgnsnls, Lender's Address
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-point source regulations per the Cupertino Municipal Code,Section :\KCI IITBCf'S Dl?CL,Ut.\TION
9.18• 1 understand illy plans shall be used a public records.
Signature Date Licensed Professional
GENERAL PERMIT APPLICATION M E r
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION ,
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 RAI
(408) 777-3228 • FAX(408)777-3333 • buildinCOCUDenino.org '\e/' v\
CUPERTINO ,��/ ��
❑PLU-1.ffi7W-7777G LJMECHANICAL [71 LECTRICAL ❑MISCELLANEOUSJ/�y
PROSECT ADDRESS l 3 �✓ �V .` 1 A- 0 �jFN� 36O Or
OWNER NAME "� `✓Irti�Z , LJ PV�'t/_DS L _ Z ( E-MAILE M
STREET ADDRESS g 3 7�3c -zJ w&-tot
L-7Y, ST.� D JOO _ ,r FAX
CONPv NF �TACT NAME L ZZ E ry _
sTRFET ADDREss D FAX
❑ jq
OWNER ❑ OWNER-SUP-DER, ❑ OV.R.MAGENTcGNT,AcmR ❑CONTR =RAGE- ❑ AR== ❑ENGDTEER ❑ DEV^....OPER ❑ iT'ANT
m N 4 4-111 uC 4 Z IJL�+s BUS.uC: - - f 011,72
CDMP �• E. FAX
STXE T DRESS CITY,5 iA i�Z[P PHO c
ARCHMECTIENGA"R NAME LICENSE NUNSER BLS.LIC x
COMPANY NAME E-MAIL FAX
STRScT ADDRESS I Cly,STATE ZIP PHONE
USE OF ❑SFDmDUPLX ❑ MULn-FAMILY PROTECT iN wGDLAND ❑ YES PRO=IN ❑YES I IS THE BLDG AN ❑ Yzs
BUILDING: ❑COMMfERCW. URBAN INTERFACE AREA ❑ NO FLOODZONE ❑NO EICHLERHOMER ❑NO
DESCRIPTION OF WORK f
0' C—
TOTALVALUATION: 3 RECEIVED BY:
By my signamrc below,I certify to each of the following: I am the property owner or authorized agent to act on the property owv&'s 15W. E I have..ad this
application and the information I have provided is correct. I have sad the Description of Work and verify it is accurate. I agcio comply with all applicable local
ordinances and sate laws minting'o building consnvction. I not 'a-representatives of Cupertino to ent r the above-idca--5e3'pro�°�1 for iinsspecfioa pu'�Oscs.
Signartm of Applicant/Agent: r� Date: B — ! �L
SUPPLEMENTAL TNFORtvIAT1ON REQUIRED OFFICE USE ONLY
y ❑ OVER-THE-COUNTER
r
❑ EXPRESS
U
J ❑ STANDARD
U
❑ LARGE
❑ MAJOR
MEP.MucApp_011.doc revised 06121111
CITY OF CUPERTINO
FEE ESTIMATOR — BUILDING DIVISION
ADDRESS: 937 blazingwood ave DATE: 10/ 912 01 2 REl'IEWED BY: larrys
APN: BP#: ��' dC/riCf�S 'VALUATION: $13,000
*PERMIT TYPE: Mechanical Permit PLAN CHECK TYPE: Alteration /Addition / Repair
PRIMARY PENTAMATION
USE: SFD or Duplex PERMIT TYPE: FURN/AC
WORK r and r furnace. add a/c unit 220 volt circuit. maintain 3 foot setback
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
A/C Units (<=10K cfm) 1BREMAIR 1 # $67
TOTALS: 1 $67.00
Mech. Plan Check 0.0 hrs $0.00 Plumb.Plan Check Elec.Plan Cherk
Mech. Permit Fee: IMPER,MIT Plumb.Permit Pee: Flee.Permit Fee:
Other Mech. Insp. 1 0.0 firs $45.00 Other Plumb Insp. El
Other Elec.Insp.
.Mech. Insp. roe: Plumb. lost.Fee: Elec.Lisp.Fe.c:
NOTE: This estinnate does not include fees(lite to other Departments(i.e. Planning, Public Narks, Fire,Sanitary Sewer District,School
District, etc. . Thesefees are based on the prelintinan information available and are tool,on estimate. Contact the De t or aldn'1 in a.
FEE ITEMS (Fee Resohnion 11-0531--ff. 7/1/111 FEE QTY/FEE MISC ITEMS
Plan Check Fee:
Suppl. PC Fee
PME Plan Check: $0.00
Permit Fee:
Suppl. Insp Fee
PME Unit Fee: $67.00
PME Permit Fee: $45.00
Construction Tar:
Administrative Fee: l tD,tlly $42.00
Work Without Permit? O Yes (F) No $0.00
Advanced Planting Sees:
Travel Documentation Fee: 1TRd1'DOC $45.00
Strong Motion Fee: IBSEISA-IICR $1.30 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $1.00
SUBTOTALS: $201.30 $0.001 TOTAL FEE: F $201.30
Revised: 10/01/2012