13020058 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 917 OLD TOWN CT CONTRArrnR! s(`UL%2 PERMIT NO:13020058
OWNER'S NAME: NATTIV MOSHE AND ESTHER DATE ISSUED:02/122013
OWNER'S PHONE: 408446724 PHONE NO:
E3 LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL U COMMERCIAL
License Class LO O Lio.N :1:337r?- REPLACE(E) 100AMP PANEL,SAME LOCATION
Contractor dLC�SLU(� t (�a[e �Z 1(Z12017j
I hereby affirm that I 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.
I hereby affirm under penalty of perjury one of the following two declarations:
1 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.Ft Floor Area: Valuation:$2200
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 APN Number:35611034.00 Occupancy Type:
permit is issued.
APPLICANT CERTIFICATION
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 ordinances and state laws relating WITHIN 180 DAYS-9F PERMIT ISSUANCE OR
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save 180 DA OM ST CALLED INSPECTION.
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the Is Date: �i 3
granting of this permit: Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18.
• - OZ O�� RE-ROOFS:
Signature �"�-� Date l 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
inspection.
❑ OWNER-BUILDER DECLARATION
Signature of Applicant: Date:
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
I,as owner of the property,or my employees with wages as their sole compensation,
will do the woik,and the structure is not intended or offered for sale(Sec.7044,
Business&Professions Code)
I,as owner of the property,am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE
construct the project(Sec.7044,Business&Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the
California Health&Safety Code,Sections 25505,25533,and 25534. I will
I hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
declarations: Health&Safety Code,Section 25532(x)should I store or handle hazardous
I have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally,should I 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 I
performance of the workfor which this.permit is issued. will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Secti s 25505,25533 ad 25534. l
Section 3700.of the labor Code;for the performance of the work for which this Owner or authorized agent:
permit is issued.
I certify that in the performance of the 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 CONSTRUCTION LENDING AGENCY
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 most I hereby affirm that there is a concoction 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 CERTIFICATION 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 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 ARCHITECT'S DECLARATION
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records.
granting of this permit.Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section Licensed Professional
9.18.
Signature Date
y IVJ.JV I .P"J:VV :...£r� �1^L'L' 71 - .y I rO.gV'.,.
Revised: 01/01/2013
c�ol937-
GENERAL
GENERAL PERMIT APPLICATION M E P
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
.10300 TORRE AVENUE•CUPERTINO,CA 950143255 �� M '
SC
CUPERTINO (408)777-3228• FAX(408)777-3333• buildingla'Dcuoertino.org
PLUMBING MECHANICAL MELECTRICAL MISCELLANEOUS
PROJECTADDRESS ( / / old— �)Tjl� _'Jy� APN#' G o3
OWNERNANM �. I L` ! V/ `, �' 7 PHONE /lPC'�1e ! / 1•-��/ ll7 n� JI
STREETADDRESS 01/ � '^ CITY,STA V o -/ /J^l 0 1�+� ��/.� /'/J.. FAX W
ct
CONTACT NAME { '/ PHONE •�L [ //Y V (E/MAIL'
STREETADDRESS CITY,STATE,ZIP FAX
❑ OwNER ❑ ow NER.BIIJIDER 13OWNERAGENT 13 CONTRACTOR 13CONTRACTOR AGENT 1:1 ARCHITECT 13ENGINEER11DEVEIAPER 13 TENANT
CONTRACTOR NAME nn LICENSENUMBER LICENSE TYPE BUS.LIC#
COMPANY NAME s' �L' !G E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
ARCHITECTIENGINEER NAME - LICENSE NUMBER BUS.LICN
COMPANY NAMEE-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF ❑SFD or DUPLEX ❑ MULTI-FAMILY PROJECT IN WID[AND ❑ YES PROJECTIN ❑YES ]BYRE BLDG AN CI YES
BUILDING: ❑ODh RCIAL URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑NO EICHLER HOMO ❑NO
DESCRIPTION OF WORK
&//01l NN)e- -e, {�Y G q h 9
v—
TOTAL VALUATION: v/ 200.00 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 olwreT&behalf. I have read this
application and the information I have provided is correct. I have read a Description of Work and verify it is accurate. I agree tomyly with all applicable local
ordinances and state laws relating to buil ' nstructi . I a r esenmtives of Cupertino to enter the above-idenuf d propeft'y for inspection pu0oses.
Signature ofApplicandAgent Date: aj/ a
SUPPLEIVENTAL INFORMATION REQUIRED OFFICEUSEONLY
❑ O\'ER-THE-COUNTER
L ,
❑ EXPRESS
Y
V
❑ STANDARD
U
❑ LARGE
❑ MAJOR
MSPMucApp_2011.doc revised 06121/11
CITY OF CUPERTINO
FEE ESTIMATOR-BUILDING DIVISION
ADDRESS: 917.OLDTOWN CT DATE: 02/12/2013 REVIEWED BY: Mendez
APN: BP#: *VALUATION: $2,200
*PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration / Repair
PRIMARY SFD Or Duplex PENTAMATION 1REAP2
USE: PERMIT TYPE:
WORK REPLACE PANEL 100 AMP
SCOPE
uwihIN xi&G
.�
MINI
Alech.Man Check, I`luuib.Phut Check Elec.Plan Check 0.0 hrs ,$0.00
Mech.Permit F.!e: Phunb.Pruni!Fee: Elec.Permit Fee:-IEPERMIT
O:hz;:14rrh. bop. Other Phunb Insp. Li
Other Elea Insp. 0.0 hrs $45.00
:Wech.Insp.I-ee. . . Plumb.Insp.Fee: di'!ec. hcsp. Fee:
NOTE:This estimate does not ineludejees due to other Departments(ie.Planning,Public Works,Fire,Sanitary Sewer District,School
District etc. . Thesefees are based on the relimina in ormadon available and are only an estimate Contact the Dept for addn't info.
FEE ITEMS (Fee Resolution 11-053 E . 711112) FEE QTY/FEE I MISC ITEMS
Plan Check Fee: $0.00 100 amps Electrical
Suppl.PC Fee: Q Reg. Q OT 0.0 hrs $0.00 $45.00 IBELEC200 I Services
PME Plan Check: $0.00
Permit Fee: $0.00
Suppl. Insp.FeelD Reg. Q OT 10.0 1 hrs $0.00
PME Unit Fee: $0.00
PME Permit Fee: $45.00
C'nnslrsc•tinq Tar:
Administrative Fee: IADMIN $42.00
Work Without Permit? ® Yes (E) No $0.00 0
Advanced Planning Fee: $0.00 Select a Non-Residential 0
Travel Documentation Feer 1TRAVDOC $45.00 Building or Structure
Strong Motion Fee: ISSEISMICR $0.50 Select an Administrative Item
Bld¢Stds Commission Fee: 1RCESC 1 $1.00
$133.50 $45.00 TOTAL FEE ` $178.50
Revised: 01/01/2013