11090197 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10371 N BLANEY AVE CONTRACTOR:A-1 ELECTRIC PERMIT NO: 11090197
OWNER'S NAME: DECKER JOHN T TRUSTEE&ET AL 421 E HEDDING ST DATE ISSUED:09/28/2011
OWNER'S PHONE: 4087187738 SAN JOSE,CA 95112 PHONE NO:(408)975-9171
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class WaO(t4, Lic.# C--Ick
c , MECH r RESIDENTIAL COMMERCIAL
Contractor po CLEC"Q-�t_ Date C`—2.,—k I
I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:ELECTRICAL SERVICE CHANGE OUT 125AMP
(commencing with Section 7000)of Division 3 of the Business&Professions **SEE NOTES**
Code and that my license is in full force and effect.
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
performance of the work for which this permit is issued.
I have and will maintain Worker's Compensation Insurance,as provided for by Sq.Ft Floor Area: Valuation:$1550
Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued.
APPLICANT CERTIFICATION APN Number:31633004.00 Occupancy Type:
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 PERMIT EXPIRES IF WORK IS NOT STARTED
upon the above mentioned property for inspection purposes. (We)agree to save
indemnify and keep harmless the City of Cupertino against liabilities,judgments, WITHIN 180 DAYS OF PERMIT ISSUANCE OR
costs,and expenses which may accrue against said City in consequence of the 180 DAYS FROM LAST CALLED INSPECTION.
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. Issued by: -- Date G�-- "' /
Signatur C+Date `-2e--kI
`^ OWNER-BUILDER DECLARATION RE-ROOFS:
All roofs shall be inspected prior to any roofing material being installed.If a roof is
..creby affirm that I am exempt from the Contractor's License Law for one of installed without first obtaining an inspection,I agree to remove all new materials for
the following two reasons: inspection.
I,as owner of 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(Sec.7044, Signature of Applicant: Date:
Business&Professions Code)
I,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business&Professions Code). ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
I hereby affirm under penalty of perjury one of the following three
declarations: HAZARDOUS MATERIALS DISCLOSURE
I have and will maintain a Certificate of Consent to self-insure for Worker's I have read the hazardous materials requirements under Chapter 6.95 of the
Compensation,as provided for by Section 3700 of the Labor Code,for the California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain
performance of the work for which this permit is issued. compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
I have and will maintain Worker's Compensation Insurance,as provided for by 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
contaminants as defined by the Bay Area Air Quality Management District I will
permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
I certify that in the performance of the work for which this permit is issued,I shall Health&Safety Code,Sections 25505,25533,and 25534.
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 er or author' gent:
become subject to the Worker's Compensation provisions of the Labor Code,I must Date:
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
APPLICANT CERTIFICATION I hereby affirm that there is a construction lending agency for the performance of wrk's
I certify that I have read this application and state that the above information is for which this permit is issued(Sec.3097,Civ C.)
correct.I agree to comply with all city and county ordinances and state laws relating Lender's Name
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes.(We)agree to save Lender's Address
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the ARCHITECT'S DECLARATION
nting of this permit.Additionally,the applicant understands and will comply
i all non-point source regulations per the Cupertino Municipal Code,Section I understand my plans shall be used as public records.
9.18.
Licensed Professional
Signature Date
CA
GENERAL PERMIT APPLICATION MEP
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE •CUPERTINO, CA 95014-3255
(408)777-3228• FAX(408)777-3333• building(d,cupertino.org MISC
CUPERTINO
❑PLUMBING ❑MECHANICAL ®ELECTRICAL [:]MISCELLANEOUS
PROJECT ADDRESS 1 �p / APN# ^ ��
OWNER NAME PHONE 06LV 736d
EMAIL
STREET ADDRESS CITY STATE,ZIP D FAX
CONTACT NAME , PHONE E-MAIL
STREETADDRESS CITY,STATE, ZIP FAX
❑OWNER ❑ OwNER-BUILDER ❑ OWNERAGENT NTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT
C CTOR NAME LICENSE NUMBER LICENSE TYPE BUS.LIC#
COMPANY NAME E-MAIL iit N l p. j
��R mr 8>`.r,.N �-►�`�'1ST L 6(
STREET ADDRESS CITY,STATE,ZIP PHONE LfDO q
ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC#
COMPANY NAME' E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF SFD:DUPLEX ❑ MULTI-FAMILY PROJECT IN WILDLAND ❑ YES PROJECT IN ❑YES IS THE BLDG AN ❑YES
BUILDING: ❑COMMERCIAL URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑NO EICHLER HOME? ❑NO
DESCRIPTION OF WORK ,l v '5ta-, t"_Q .Lr.
TOTAL VALUATION: RECEIVED BY: J`
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 provided is correct.j have read the Description of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relatin ilding construction`` orize representatives of Cupertino to enter the above-identified property for inspection pu@oses.
Signature of Applicant/Agent: Date:'
SUPPLEMENTAL INFORMATION REQUIRED OFFICE USE ONLY
OVER-THE-COUNTER
e.
❑ EXPRESS
Y
U
T
❑ STANDARD
U
❑ LARGE
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❑ MAJOR
1EPMisc4pp_2011.doc revised 06121111
CITY OF CUPERTINO
FEE ESTIMATOR- BUILDING DIVISION
ADDRESS: 10371 n blaney DATE: 09/28/2011 REVIEWED BY: bobs.
APN: BP#: "VALUATION: $1,550
"PERMIT TYPE: Electrical Permit PLAN CHECK TYPE: Alteration /Addition / Repair
PRIMARY SFD or Duplex PENTAMATION 1 REAP2
USE: PERMIT TYPE:
IS
oRK electrical service chan a out
COPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Services 1 ERT<200 100 Amps $44
TOTALS: $44.00
IT Elec.Plan Check 0.0 1 hrs $0.00
- Elec.Permit Fee: IEPERMIT
Other Elec.Insp. 0.0 hrs $44.00
NOTE. This estimate does not include fees due to other Depts(i.a Public Works,Sanitary Sewer District,School District,etc.).
Thesefees are based on the preliminaigy in ormation available and are only an estimate. Contact the De t or addn7 info,
FEE ITEMS (Fee Resolution 11-053 Eff Z 1;'11) FEE QTY/FEE MISC ITEMS
PME Plan Check: $0.00
PME Unit Fee: $44.00
PME Permit Fee: -T-T $44.00
Administrative Fee: IADMIN $41.00
Work Without Permit? 0 Yes Q No $0.00
Travel Documentation Fee: ITRA VDOC $44.00
Strong Motion Fee: 1BSEISMICR $0.50 Select an Administrative Item
Bldv Stds Commission Fee: 1BCBSC $1.00
SUBTOTALS: $174.50 $0.00 TOTAL FEE.- F $174.50
Revised: 09/02/2011
Building Department
City Of Cupertino
10300 Torre Avenue
Cupertino, CA 95014-3255
ELI] Telephone: 408-777-3228
U P E RT I N O Fax: 408-777-3333
CONTRACTOR/ SUBCONTRACTOR LIST
JOB ADDRESS: /p 'j 1 _ �„ ` �649PERMIT# C
OWNER'S NAME: 4y,%,3 PHONE# *911DW 11C,9 ` q Sq%-1
GENERAL CONTRACTOR: _� �L��=�� BUSINESS LICENSE #
ADDRESS: 4-L4 a, _.,22f"' CITY/ZIPCOD C-,u- 9'-g-t 1 Z
*Our municipal code requires all businesses working in the city to have a City of Cupertino business license.
NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE
GENERAL CONTRACTOR AND ALL SUBCONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO
BUSINESS LICENSE.
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following information:
V 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
Ctr
Owner/Contractor Signature Date