12100136 CITY OF CUPERTINO BUILDING PERMIT
RUILDINC.ADDRESS: 10760 S STELLING RD CONTRACTOR:MCCLELLAN PERMIT�N'O: 12100136
DEVELOPMENT
OWNER'S NAME: BOLLINGER VENTURE LLC 1448 F,NI'RADA VERDE PI, DATE ISSUED: 10mrz012
OR;NER'SPIIONE: 9259449108 ALAMO.CA 94507 PHONE NO:(925)944-9108
❑ ' LICENSED CONTRACT'OR''SS CDECI,ARA'I'ION BUILDING PERNIIT INFO: BLDG r ELECT r PLUNIR
License Class Cass_ Lica �, C �P
' s E (�1.VY. � I p1ECH (- RESIDENTIAL rI COMMERCIAL(J
Contractor �~`E h � `Date j9 k
hereby affirm that I am licensed under the provisions of IeI JOB DESCRIPTION: REMOVE AND REPLACE MAIN ELECTRICAL SERVICE
(commencing with Section 7000)of Division 3 of the Business&Professions (200
Code and that my license is in full force and effect. AMP)
hereby affirm under penalty of perjum 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.
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 Sq.Pt Floor Area: Valuation:$1600
permit is issued.
APPLICANTCERT'IFICATION APN Number:35922078.00 Occupancy Type:
I certify that I have read this application and stale that the above information is
correct.1 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 inspersion purposes. (We)agree to sate PERMIT EXPIRES IF WORK IS NOT STARTED
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the WITHIN 180 DAYS OF PERMIT ISSUANCE OR
granting of this permit. Additionally,the applicant understands and will comply 180 DAYS FROM LAST CALLED INSPECTION.
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18.
Issuedhy: ,��i9/� �TGr( Date:A;'17Ia
Signature "LdomDate
❑ OWNER-BUILDER DECLARATION
RE-ROOFS:
hereby affirm that I am exempt from the Contractor's License Law for one of All roofs shall be inspected prior to any roofing material being installed.If a roof is
the following two reasons: installed without first obtaining an inspection,I agree to remove all new materials for
I,as owner of the property,or my employees with wages as their sole compensation; inspection.
will do the work,and the structure is not intended or offered for sale(Sec.7044,
Business&Professions Code) Signature of Applicant: Date:
I,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(See.7044,Business&Professions Code). ALL ROOF COVERINGS T'O RE CLASS"A"OR BETTER
hereby affirm ander penalty of perjury one of the following three
declarations:
I have and will maintain a Certificate of Consent to self-insure for Worker's IIA'hARUOl1S Nh\TIiRh\IS DISCLOSURE
Compensation,as provided for by Section 3700 of the Labor Code,for the I have read the hazardous materials requirements under Chapter 6.95 of the
performance of the work for which this permit is issued. California Ilealth&Safely Code.Sections 25505,25533,and 25534. 1 will maintain
I have and will maintain Worker's Compensation Insurance,as provided for by compliance with the Cupertino Municipal Code.Chapter 9.12 and the Ilealth&
Section 3700 of the Labor Code,for the performance of the work for which This Safety Code,Section 25532(x)should I store or handle hazardous material.
AJditionalh.,should I use equipment or devices which emit hazardous air
permit is issued. contaminants as defined by the Ray Arca Air Quality Management District 1 will
I certify that in the performance of the work for which this permit is issued.I shall maintain compliance with the Cupertino Municipal Code.Chapter 9.12 and the
not employ any person in any manner so as to become subject to the Worker's Ilealth&Safety Code,Sections 25505,25533,and 25534.
Compensation laws of California. If,after making this certificate ofexemption,I
become subject to the Worker's Compensation provisions of the Labor Code,I must Ou'ner vu nr'.eJ gene l9 C). �.� . -
forthwith comply with such provisions or this permit shall be deemed revoked. Date.
APPLICANT CERTIFICATION CONS'IRIICI'ION LENDING AGENCY
I certify that I have read this application and state that the above information is I hereby afLrn that there is a construction lending agency for the performance of nark's
cored.I agree to comply with all city and county ordinances and stale laws relating for which this permit is issued(Sec.3097,Civ C.)
to building construction,and hereby authorize representatives of this city to enter Lender's Name
upon the above mentioned property for inspection purposes.(We)agree to save
indemnify and keep harmless the Ciry of Cupertino against liabilities,judgments, 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 ARCIIITECI"S DECLARATION
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18. I understand my plans shall be used as public records.
Signature Date Licensed Professional
GENERAL PERMIT APPLICATION M E P
C COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION
10300 TORRE AVENUE •CUPERTINO, CA 95014-3255 w A
GUPERTINO (408) 777-3228 • FAX(408)777-3333• building0cuoertinO.orD '�a/'
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USE OF FD aDUPLJ! ❑ MULT FAMS.YPROJECJ IN WIl.OVNO ❑ YS PROJECTN ElYES 15 THE RIDG AN ❑ YES
BIJTLDBRG: COMFL�AOAL LRBAJ+PTcRFACE(ARRE,AA NO FLOOD ZONE NO flCHLDR HOFLTT O
DESCRJlrnONOF WORR
TOTAL VALUATION: D I RECEIVED BY:
By my sipzwrc below,I certify to each of the following: I am the property owner or ashorzcd agent m act on the propr.,y owner's behalf. I have rend tis
application and Rhe info,-ation I have provided is comcL I have read the Descriptirzrof Worc and verify it is accurate. I a� al
to comply with all applicable]Dc
PJ
and state laws relating to building cons n da Ian orm ep sen tive unenino to enter the above-id=Un7ed prope:,y for inspection put;Doses.
Signatw-c of ApplicanNP.genc Date:
SUPPLEMENTAL INFORMATION RgQOFFICE USE ONLY
t OVER-THE-COUNTER
❑ Exr RESS
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❑ STANDARD
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❑ MAJOR
:NrP3fse9pp_2011.doc rervSed 06121/11
CITY OF CUPERTINO
FEE ESTIMATOR - BUILDING DIVISION
ADDRESS: 10760 So Stelling DATE: 10/17/2012 REVIEWED BY: Sean
APN: BP#: 'VALUATION:
*PERMIT TYPE: Electrical Permit PLAN CIIECK TYPE: Alteration /Addition / Repair
PRIMARY PENTAMATION
USE: SFD or Duplex PERMITTYPE: 1REAP2
WORK Remove and replace main electrical service 200 amp).
SCOPE
APPLIANCE./EQUIP TYPE FEE ID QTY UNITS BP FEES
Services 1ERT<200 200 Amps $45
TOTALS: $45.00
6fech. Plan Check Plumb.Plon Check Elec. Plan Check 0.0 1 hrs $0.00
Mock Permit Fee: Plumb.Permit rec.- Elec. Permit Fee: IEPERMIT '
Other Afech. Insp. Other Plumb Insp. Other Elec.Insp. 0.0 hrs $45.00
klech. bap. Fac: Plumb. hist). Fee: Occ.bap. Fee:
NOTE: This estimate does not include jeer due to other Departments(i.e. Planning, Public Works, Fire,Sanitary Sewer District,School
District, etc). These feev are base!/on the prelintinan information available and are only,an estinare. Contact the De t or adtln 7 info.
FEE ITEMS (Fee Resohuion 11-053 Eff 7///12) FEE QTY/FEE MISC ITEMS
Plan Check Fee:
Suppl. PC Fee
PME Plan Check: $0.00
Permit Fee:
Supp/. lits'p Fee
PME Unit Fee: $45.00
PME Permit Fee: $45.00
Construction Tar:
Administrative Fee: IADhfIN $42.00
Work Without Permit? Q Yes (j) No $0.00
Advanced Platting Fees:
Travel Documentation Fee: ITR.tVDOC $45.00
Strong Motion Fee: /BSEISMICR $0.50 Select an Administrative Item
I31dg Stds Commission Fee: IBCBSC $1.00
SUBTOTALS: $178.50 $0.00 TOTAL FEE: $178.50
Revised: 10/01/2012