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11100102CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 20977 FAIRWOODS CT CONTRACTOR. T -B5 - TO B PERMIT NO: 11100102 PgT-94NII►IED OWNER'S NAME: SUSAN VERGHO WNER'S PHONE: 4088293050 E. LICENSED CONTRACTOR'S DECLARATION License Class C— �o Lic. # Ll50-7ZO Contractor S w AcA,,,1 C t e c_�; L Date 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: 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 permit is issued. APPLICANT CERTIFICATION 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 indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs, and expenses which may accrue against said City in consequence of the 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. 7 Sign � Date 6 t OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: 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, Business & Professions Code) I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec.7044, Business & Professions Code). I 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 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 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 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 forthwith comply with such provisions or this permit shall be deemed revoked. APPLICANT CERTIFICATION 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 ,►pon the above mentioned property for inspection purposes. (We) agree to save demnify and keep harmless the City of Cupertino against liabilities, judgments, ,;osts, and expenses which may accrue against said City in consequence of the 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. Signature Date DATE ISSUED: 10/14/2011 L- I-eL � I PHONE NO: JOB DESCRIPTION: RESIDENTIAL INSTALL OF MANUAL TRANSFER SWITCH FOR A FUTURE PORTABLE GENERATOR UNIT Sq. Ft Floor Area: I Valuation: $2400 APN Number: 35913115.00 1 Occupancy Type: PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAY M LAST CALLED IN. Issued by: �Wvg�/ Date: 16711 RE -ROOFS: 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. Signature of Applicant: Date: ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER HAZARDOUS MATERIALS DISCLOSURE I have read the hazardous materials requirements under Chapter 6.95 of the California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Section 25532(a) should I store or handle hazardous material. Additionally, should I use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management District I will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Sections 25505, 25533, and 25534. j Owner or authorized agent: s Date: () t CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of work's for which this permit is issued (Sec. 3097, Civ C.) Lender's Name Lender's ARCHITECT'S DECLARATION I understand my plans shall be used as public records. Licensed Professional CITY OF CUPERTINO WE FEE ESTIMATOR - BUILDING DIVISION APPLIANCE / EQUIP TYPE ADDRESS: 20977 fairwoods ct. DATE: 10/14/2011 REVIEWED BY: bobs. UNITS APN: BP#: "VALUATION: 1$2,400 *PERMIT TYPE: Electrical Permit PLAN CHECK TYPE: Alteration / Addition / Repair PRIMARY SFD or Duplex lex USE: # PENTAMATION 1 REAP? PERMIT TYPE: WORK installation of manual transfer switch for a future portable generator unit. SCOPE APPLIANCE / EQUIP TYPE FEE ID QTY[FEE QTY UNITS BP FEES Special Circuits 1BREMMISC 1 # $130 PME Unit Fee: $130.00 PME Permit Fee: $44.00 Administrative Fee: ]ADMIN $41.00 Work Without Permit? 0 Yes (E) No $0.00 TOTALS: Travel Documentation Fee: ITRA VDOC $130.00 St_rona Motion Fee: IBSEISMICR Elec. Plan Check 10.0 1 hrs $0.00 Elec. Permit Fee: IEPERMIT Other Elec. Insp. 10.0 hrs $44.00 NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, sanitarysewer Vistrict, scnool F%.*- TL,...,. F ,..... ., 1. .....,.1 nu 4L— ('nntnet tho Dont for addn'l info_ FEE ITEMS (1 ee Resolution 11-055 Bf '-1.1111) FEE QTY[FEE MISC ITEMS PME Plan Check: $0.00 PME Unit Fee: $130.00 PME Permit Fee: $44.00 Administrative Fee: ]ADMIN $41.00 Work Without Permit? 0 Yes (E) No $0.00 Travel Documentation Fee: ITRA VDOC $44.00 St_rona Motion Fee: IBSEISMICR $0.50 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $1.00 SUBTOTALS: $260.50 $0.00 TOTAL FEE: $260.50 Revised: 10/01/2011 CUPERTINO GENERAL PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT - BUILDING DIVISION 10300 TORRE AVENUE - CUPERTINO, CA 95014-3255 (408) 777-3228 - FAX (408) 777-3333 - building(aD-cupertino.om ❑ PLUMBING ❑ MECHANICAL EAELECTRICAL ❑ MISCELLANEOUS MEP MISC 11100 10 2__� PROJECT ADDRESS L yo�� Q G� CV' APN# �G} I r\C) l lJ OWNER NAME �GV�v� 2.r PHONE %% 1��$ Z — O E-MAIL Gi/A"a_At(QM STREET ADDRESSV� CITY, STATE, ZIP FAX CONTACT NAMEHONE E-MAIL STREET ADDRESS CITY, STATE, ZIP eattio' 93(0 FAX ❑ OWNER ❑ OWNER -BUILDER ❑ OWNER AGENT ;&CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME i `J�.11n ,�Ib�v��n LICENSE NUMBER �5O'72o LICENSE TYPE 10 G - BUS. LIC # COMPANY NAMEE-MAIL �w;�-�h�� e��tc(�,r�t, St�ln �g c144 FAX STREET ADDRESS�2 7 CITY, STATE, ZIP �} 'q PHONE=CjQ-/ ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS. LIC # COMPANY NAME E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE USE OF %SFD or DUPLEX ❑ MULTI -FAMILY BUILDING: ❑ COMMERCIAL PROJECT IN WILDLAND ❑ YES URBAN INTERFACE AREA W NO PROJECT IN ❑ YES FLOOD ZONE 'gNO IS THE BLDG AN ❑ YES EICHLER HOME? NO DESCRIPTION OF WORK Tj � 11 k.;. L k1 et 0 Q Me"iiI'l TOTAL VALUATION. 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 provided is correct. 1 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 building nstr I e representatives of Cupertino to enter the above -identified property for inspection purposes. I Signature of Applicant/Agent: Date: 1G ZO L SUPPLEMENTAL INFORMATION REQUIRED O USE ONLY C ., OYER -TITS COUNTER MRUS` STANDARD 0 LARGE 13 MAJOR MEPMiscApp_2011.doc revised 06/21/11