12110066 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 20810 MC CLELLAN RD CONTRA( IfOR:IES RESIDENTIAL.INC PERMITNO: 12110066
OWNER'SNAME:' IGS AM'AEKla LT- /LZ AAA J-Vu54 840667'11,\\'E DATE ISSUED: IUIY2012
OWNER'SPBONE: 5106497800 OAKLAND.CA 94621 PHONE NO:(510)838-9000
❑ LICENSED CONI-RACI'OR'S DECLARATION BUILDING PERMIT INFO: BLDG r ' ELECT❑ PLUMB
License Class C_1 0 - Lie.4 G ��2-&1:1 r_ r r
M1IECFI RESIDENTIAL COMMERCIAL
Contractor JAS 0,1 SCKJ1 'T Date )k-( Z, - IZ
1 hereby affirm that 1 am licensed under the provisions of Chapter 9 JOB DESCRIPTION: INSTALLATION OF LEVEL 2 CHARGING STATION WITII
(commencing with Section 7000)of Division 3 of the Business S Professions 60
Code and that my license is in full force and effect. AMP AC DISCONNECT
I 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 -
perlbrmance 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. FI Fluor Area: Valuation:$925
peril is issued.
`AI'PLIC,\N'T'CISR'1'11'ICA'I'ION APN Number:35920041.00 Occupancy Ty 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,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.-
osts,indemnify expenses
harmless the crue'aty f Cupertino against liabilities,judgments. WITHIN 180 DAYS OF PERMIT ISSUANCE OR
costs,and expenses which may acerae against said City in consequence of the
granting of this permit. Additionally,the applicant understands and will comply 180 DAYS FROM LAST CALLED INSPECTION.
with all non-point urce regulatims per the Cupertino Municipal Code,Section
9.18.
Issued by: �F�/✓ ��f Date://•/3 •�
Signature �( Date ���(�•�Z.
❑ OWN(. -RUl LI3ER DECLARATION -
RF-ROOFS:
hereby affirm that I am exempt from the Contractor's License Law formic of All roofs shall be inspected prior to any roofing material beitg installed.If a roof is
the following two reasons: installed without first obtaining an inspection,1 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 Applicud: Date:
I,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business&Professions Code). AL1,ROOF COVI?RINGS TO BE CLASS"A"OR BEYFER
I hereby affirm under penalty of perjury one of the following three
declarations: IIA%ARDOUS MATERIALS DISCLOSURE
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 I have read the hazardous materials requirements under Chapter 6.95 of the
performance of the work for which this permit is issued. California I leallh&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 Ileallh&
Section 3700'ofthe Labor Code,for the performance of the work for which this Safe[' Code.Section 25532(u)should I store or handle hazardous material.
Additionally,should I use equipment or devices which emit h�aardous air
permit is issued. contaminants as defined by the Bay Area Air Quality Management District I mill
I certify that in the perforance of the work forwhich 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'sIlealth aret) Code,Sections 25505,25533,and 25534.
Compensation Imps of California. If,after making this certificate of exemption,I
become subject to the,Worker's Compensation provisions of the Labor Code,I mustOwn arm t arized age '
Date:
forthwith comply.yvilh such provisions or this permit shall be deemed revoked.
APPLICA\I'CF.RT'IFICATION CON'S' RUCTION LENDING AGENCY
I certify that I have read this application and state that the above infomtation is I hereby aff nn thin there is a construction lending agency for the performance of Nark's
coffee(. I agree In 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 enter Lender's Name
upon the above mentioned property for inspection purposes.(We)agree to save
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 pemtil.Additionally,the applicant understands and will comply ARCI liTE.CI"3 DECLARATION
with all non-point source regulations per the Cupertino Municipal Code,Sectio
9.18. I understand my plans shall be used ass public records.
Signature Date Licensed Professional
Building Department
City Of Cupertino
10300 Torre Avenue
Cupertino, CA 95014-3255
Telephone: 408-777-3228
C U P E RT I N O Fax: 408-777-3333
CONTRACTOR / SUBCONTRACTOR LIST
JOB ADDRESS: LF> t q t_, PERMIT# 1 2 t 1 '
OWNER'S NAME: P.v`1vcr�c 6 PHONE # - 7,%-5- Oo
GENERAL CONTRACTOR:-CTr�C— BUSINESS LICENSE #
ADDRESS: I&qo 66`'A' .4v6 . CITY/ZIPCODE:O Kln�JO G °( ' 2
*Our municipal code requires all businesses working in the city to have a City of Cupertino business license.
NO BUILDING FINAL OR FINAL OC UPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE
GENERAL CONTRACTOR AND ALL U ONTRACTORS HAVE OBTAINED ACTT-Y OF CUPERTINO
BUSINESS LICENSE.
I am not using any subcontractors: t l- t 3 - Z
Signature ,Date
Please check applicable subcontractors and complete the Awing 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_
CITY OF CUPERTINO
FEE ESTIMATOR - BUILDING DIVISION
ADDRESS: 20810 McClellan PI DATE: 11/13/2012 REVIEWED BY: Sean
APN: BP#: 'VALUATION: $925
*PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration / Repair
PRIMARY SFD or Duplex PENTAMATION SOLAR-RES
USE: PERMIT Tl'PE:
WORT: Installation of level 2 charging station with 60 amp AC disconnect.
SCOPE
Meth. Plan Check, Plumb. Plan Check Elec. Plan Check 0.0 hrs $0.00
Alech. Permit Fee: Plnnth. Permit Fee: Elec. Permit Fee: IEPERAIIT
Other Alech. Insp. Other Plumb Insp. Other Elec. Insp. 0.0 hrs $45.00
Mech.Imp. Fee: Plumb. Insp.Fee: Elee.lay.Fee:
A'OTE: This wtihtate does not include jeer due m other Departments(i.e. Planning, Public Works. Fire,Sanitary Seiner District,School
District,etc. . These ees are based on the relintinan•information available and are only an estimate Contact the Dept for atldn'I info.
FEE ITEMS (Fee Resohaion 11-053 F_lL 7/1/12) FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.0011 # Alternative Energy System
Suppl. PC Fee: Q Reg. () OT 0.0 hrs $0.00 $102.00 10IROSTA EV Charging Station
PME Plan Check: $0.00 60 amps Electrical
Permit Fee: $0.00 $45.00 IERT<200 Services
Suppl. Insp. Fee-.0 Reg. Q OT 1 0.0 1 hrs $0.00
PME Unit Fee: $0.00
PME Permit Fee: $45.00
Construction Tax
Administrative Fee: 1ADMIN $42.00 O
Work Without Permit? O Yes (E) No $0.00 G
Advanced Planning Fee:. • $0.00 Select a Non-Resideniial
-Travel Documentation Fee: ITRA I DOC $45.00 Building or Structure 0 .
Strong Motion Fee: tBSE1S,t41CR $0.50 Select an Administrative Item
Blde Stds Commission Fee: IBCBSC $1.00
SUBTOTALS: $133.50 $147.001 TOTAL FEE: $280.50
Revised: 10/01/2012
j Z I ( civ Co �v
ALTERNATIVE ENERGY PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION
10300 TORRE AVENUE• CUPERTINO, CA 95014-3255 At
(408)777-3228• FAX(408)777-3333• buildine(dcuger ino.org
CUPERTINO
PROJECT ADDRESS �!�� \� n� I APNB ':5 g
OWNER NAME C/ 1i C PHONE E-MAIL
I L&" eQ t'jbSj Sid - it0p
-� STREETADDRESS CITY,STATE,ZIP FAX
«/ O Mf�.
CONTACT NAME PHONE E-MAIL
STREET ADDRESS CITY.STATE. ZIP FAX
WNER ❑ OWNER-BUILDER ❑ OWN AGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME�� N 1 ^ LICE NSENUMBE ( LICENSETYPE 1� I BUS.LICd
COMPANY NAME !'�/1" aJ E-MAIL 1..� FAX
�S 251 ,r-�SIa.L
-STREET ADD S CITY,STATE,ZIP PHONE
0 6G Av P n r AG i 5to 3$3- `1ooJ
ARCHITECTIENGINEER NAME LICENSE NUMBER I BUS,LIC M
COMPANY NAME E-MAIL FAX
STREET ADDRESS I CITY,STATE.ZIP PHONE
USE OF / - SFD or Duplex .❑ Multi-Family PROJECT IN WILDLAND PROJECT IN J
STRUCTURE: /❑_ Commercial URBAN INTERFACE AREA ❑ )C-
Yes Q]-NO FLOOD ZONE ❑ Yes 17nN0
❑ SOLAR PANELS ELECTRIC VEHICLE CHARGING STATION ❑ SOLAR WATER HEATING ❑ OTHER: 777
FORSOIARPANEI_S: NUMBER OF PANELSIUVTS: IKILOW'ATTS: TOTAL VALUATION
25. ao
DESCRIPTION OF WORK
'.RECEIVED BY:' �.
By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on the property owner's behalf. I have read this
application and the information I have prov'ded iS correct- I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating to buil, g struction a I rice representatives of Cupenino to enter the above-identified property for inspection purposes.
Signature of ApplicanOAgenC ! Date:
'SUPPLEM rTALINFORMr)%1`IONREQUIRED OFFICEUSEONLY
OVER-THE-COUNTER
Y
_ ❑ EXPRESS
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❑ STANDARD
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❑' LARGE
❑ ,MAJOR
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