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12110100CITY OF CUPERTINO BUILDING PERMIT RUILDINGADDRESS: 11234CATALINACT CONTRACI'OR: JOHN SULLIVAN PF,RMITNO: 12110100 CONSTRUCTION OWNEWSNAMF: HUMNICKYTRUST- 960 OPAL DR DATE ISSUED: II/162012 OWNER'S PHONE: 4084316161 SAN.IOSE. C\ 95117 PIIONE NO: (408).R 04254 ❑ LICENSED CONI'RAC`fOR'S DECLARATION r r1 r ELECT PLUMB kS3� BUILDING PERMIT INFO: BLDG License ClassLie. R 17 yr —�i /t �6% DIECFIr RESIDENTIAL❑ COMMERCIAL �3:tIDamContractor hereby affirm that 1 am licensed tinder the provisionsof Chapter9 JOB DESCRIPTION: ELECTRICAL PANEL CHANGE our 17ROM i00TO200 (commencing with Section 7000) of Division 3 of the Iiusiness & Professions AMPS & REPLACE SEWER LINE Code and that my license is in full force and effect. hereby affirm under penally of perjuryone 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 work for which this penult is issued. I have and will maintain Worker's Compensation Insurance, as provided for by Sq. Ft Fluor Area: Valuation: $4000 Section 3700 of the Labor Code, for the performance of die work for which this permit is issued. ARNNtimber: 35621042.00 Occupancy Type: APPLIC,UVI'CERTIFICVfION I cenifiv that I have read this applicalion and state that the above information is correct. I agree to comply with all city and county ordinances and state Imus 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 PERMIT EXPIRES IF WORK IS NOT STARTED 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 WITHIN 180 DAYS OF PERMIT ISSUANCE OR grunting of this permit. Additionally, the applicam understands and will comply 180 D S FROT CALLED INSPECTION. with all non-point source regal If a the Cupertino Municipal Code, Section 9.18. r //_ 16 - P_ Issued by: Date: Signature Date /� r�O •/ ❑ OWNER-BUILDER DECLARATION RE: ROOFS: 1 hereby affirm that I am exempt from the Contractor's License Lae' for one of All roofs shall be inspected prior to .my roofing material being installed. If a roof is the following two reasons: installed without first obtaining:m inspection. I agree to remove all new materials for I, as owner of the property, or tiny 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 Appli©nC Date: I, as owner of the property, am exclusively contracting with licensed contractors to construct the pioject (Seo.7044, Business & Professions Code). .U,I, ROOF COVFRINGS'f0 141? CLASS ".\" OR ISE: I-fliR hereby affirm under penalty of perjury one of the following three declarations: I have and will maintain a Certificate of Consent to self-insure for Worker's II,\'!.,\RDOIIS MA'I'E:RIAIS 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 & Safety Code. Sections 25505, 25533, and 25534. I 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 & Safety Code. Section 25532(a) should I store or handle hazardous material. Section 3700 of the Labor Code, for the performance of the work for which this Additionally, should I use equipment or devices which emit hazardous air permit is issued. contaminants as defined by the Bay Area Air Quality Management District I 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 tiny person in any manner so as to become subject to the Worker's Health & Safety Code. Sections 25505, 25533, and 25534. Compensation laws of California. If, after making this certificate of exemption, I become subject to the. Worker's Compensation provisions of the Labor Code, I must Owner(a rut wiz ag n (7 forthwith comply with such provisions or this permit shall be deemed revoked. Date. CONSI'RUCI'ION LENDING AGENCY APPI,IC\\ I' CFR'1'IFIC\"I'ION I cenify that I have read this application and state that the above information is I hereby affnrn that there is a construction lending agency for the performance of 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, Cir 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 sate indemnify and keep harmless the City 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 ARCII ITECI"S DECLARATION with all non-point source regulations per the Cupertino Municipal Code, Section 9.18. 1 understand my plans shall be used as public records. Signature Date Licensed Professional B CUPERTINO Mmi GENERAL PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISIO< 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 • buildinalcDcua=-rtino.ora IZI�0iaC, MEP rTr.ul' ea1G Flm�C::J_N:cAL FCl.=CAI.—I>✓�sc�ur_ovs mise PROT'SADDRESS 1(3 (FJ — �- nr-�I OWNERNAa� gar" Ya 14h r-,. � Ie eHe �s 31-P I MkM I E" fz4v _ PQ IQh �YuJ+OO,fit s R—, ADDRESS '1 13 y Ca'fia I ti w Ll �4 , KD Lr I F ' COMAR NAME �" \. ( VLl/� u` / C O I cu_Cok7� -31''_ L( 15 CI I � it 'U S (alrK, L6 5; Clr. STA. •S z? F.4C ❑ OWNS ❑ OWNa-BUIlDMt ❑ OWMAAGTI..T❑ CONT CMR ❑CONTRAC70RAG T. ❑ AR=T ❑ ENGNcER ❑ DEZZZPER [3 7Iu\T MIM1 CTOR NAME 3o I- 4 � yam\ I L]CENsB 'q S ,' `( S1,L�N?, I BUS. IJC% CONC-ANY NAM': I, I ` CO s'li 11'ttL;�'.fiv-� - MALJ G I l , vo, co-�(� � �6 ryo0. iO I AX q qt SLR -=f ADDRESS 76o 019AL OR - y '`l •STA`e. µ., lore C`"r 9�/I? 2AONE /-o 6-3�s-v�-s'�( ARC' r.NGBN=. NAME LICENSE NUMJ;ER 1BUS. L1C d COWANY NAME' E -MAL FAX STREET ADDRESS I CIS', S(AT; ISP I PHONc USE OF ❑ SFJ . DUPIJX ❑ M 7L FAMLY SU I.ZWG: ❑COMM- 0C PROTZCT N WDDL.ND ❑ )--S I UR3A.NNTERFACSAREA ❑ NO PROSECT N ❑ YS 2100D7 ❑ NO is TF= BLDG AN ❑ YS MOC—RHOI'm ❑ NO DESCIUYION OF WORK , ep1�I: e , ^ a TOTP� YALL'AT10:J; �(JQ; Re_CE7VED 3Y: 3y my signs --e below, I c---dy to eaen of the oflowing: I zn :be propery o-ncr or z=lIoriztd aeect to act of she ovpcy own. -s's behalf. I have read tis application and the into. -axion I bzve protdded is correct I bzve :gad fie Desciption of WorF: znd ve ,y it is zco�zte. (x�co"ro comply axil zll zoplicable loczl or di-.nces and stzte laws relating to building consapetion. I mtbo,-;a mpmsentzrives of Cuv:nno to enter the above -identified propry :or inspection pu;�'oses. Sig"^.ecut of ApplicanyAgene Date: SU-PPLEMENT.AL INFO7Q LATION REQUIRED ' OFFICE USE ONLY u J ❑ OVER-THE-COUNTER ❑ EXPRESS ❑ s-rANDARO ❑ LARGE ❑ MAJOR .M-.:'pMse4pp_201 Ldoc revised 06121/11 )V�j ON CITY OF CUPERTINO FEE ESTIMATOR—BUILDING DIVISION NOTE: This estimate does not includejeev due to other Departments (i.e. Planning, Public II'orAs, Fire, Sanitary Saver District, School District. etc.). Theve fees are based on the mrellntinan• information availahle and are only an estimate. Contact the Dept for addn'I info. FEE ITEMS (ree Resolution 11-053 E/7 7/1/12) ADDRESS: 11234 catalina ct DATE: 11116/2012 REVIEWED Bl': larrys Alech. Perndt ree: APN: BP#: 'VALUATION: $4,000 •PERt:IIT TYPE: Building Permit PLAN CHECK TYPE: Addition PRIMARYPENTAMATION USE: SFD or Duplex Elce. insp. Fee: PERMIT TYPE: 1REAP i YORK alae panel change out from 100 to 200 amps... replace sewer line SCOPE $0.00 NOTE: This estimate does not includejeev due to other Departments (i.e. Planning, Public II'orAs, Fire, Sanitary Saver District, School District. etc.). Theve fees are based on the mrellntinan• information availahle and are only an estimate. Contact the Dept for addn'I info. FEE ITEMS (ree Resolution 11-053 E/7 7/1/12) ,Llech. Plan Check Plumb. Plan Check 0.0 1 hrs $0.00 L'Iec. Plan Check 0.0 1 hrs $0.00 Alech. Perndt ree: Plumb. Permit Fee: IPPF-RifIT Elec. Permit Fee: /EPERAHT Other Alech. /mvp. Other Plumb Insp. 0.0 hrs $45.00 Other Elec. Insp. 0.0 Mech. Insp. ree: Plumb. Insp. ree: Elce. insp. Fee: NOTE: This estimate does not includejeev due to other Departments (i.e. Planning, Public II'orAs, Fire, Sanitary Saver District, School District. etc.). Theve fees are based on the mrellntinan• information availahle and are only an estimate. Contact the Dept for addn'I info. FEE ITEMS (ree Resolution 11-053 E/7 7/1/12) FEE QTY/FEE MISC ITEMS Plan Check Fee: $0.00 200 amps $45.00 Electrical /ERT<200 I Services Suppl. PC Fee: Q Reg. O OT 0.0 hrs $0.00 PME Plan Check: $0.00 1 # $23.00 Plumbing IPRSEUIER Sewer, Sanitary Permit Fee: $0.00 Suppl. Insp. Fee0 Reg: Q OT T0,0Thrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $90.00 Conso-uction Tax: Administrative Fee: IADMIN $42.00 O E) Work Without Pennit? 0 Yes Q No $0.00 Advanced Planning Fee:. $0.00 Select a Non -Residential Building or Structure 0 i Travel Documentation Fee: ITRA vDOC $45.00 Strong Motion Fee: IBSPISAdCR $0.50 Select an Administrative Item 131dg Stds Commission Fee: IBCBSC $1.00 SUBTOTALS: $178.501 $68.00 TOTAL FEE: $246.50 Revised: 10/01/2012