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09100033 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10268 CRESTON DR CONTRACTOR:CHAMBERLAIN STEPHEN PERMIT NO:09100033 OWNER'S NAME: CHAMBERLAIN STEPHEN 10268 CRESTON DR DATE ISSUED: 10/05/2009 ER'S PHONE: 4087393040 CUPERTINO CA,CA 95014-1014 PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class Lic.# MECH f- RESIDENTIAL f- COMMERCIAL Contractor Date I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:CHANGE OUT EXISTING 100 AMP ELECTRICAL (commencing with Section 7000)of Division 3 of the Business&Professions SERVICE TO Code and that my license is in full force and effect. A 200 AMP PANEL 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. I have and will maintain Worker's Compensation Insurance,as provided for by Sq.Ft Floor Area: Valuation:$500 Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. APN Number:32637038.00 Occupancy Type: 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 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 D YS 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 / O 9.18• Issued by 0 �� Date: Signature Date OWNER-BUILDER DECLARATION RE-ROOFS: All roofs shall be inspected prior to any roofing material being installed.If a roof is hereby 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. 1,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) 1,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 HAZARDOUS MATERIALS DISCLOSURE declarations: 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. 1 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 One r authorizeC� become subject to the Worker's Compensation provisions of the Labor Code,I must �'. i Date: 1 ".6 —0 / forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY APPLICANT CERTIFICATION 1 hereby affirm that there is a construction lending agency for the performance of work's 1 certify that 1 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 it- -lify and keep harmless the City of Cupertino against liabilities,judgments, C. ad expenses which may accrue against said City in consequence of the gran ring of this permit.Additionally,the applicant understands and will comply ARCHITECT'S DECLARATION witY,all non-point source regulations per the Cupertino Municipal Code,Section I understand my plans shall be used as public records. 9.18. e___ Licensed Professional Signature r- Date_j �' CITY OF CUPERTINO 5 ITEMS OF 5 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot : APN . . . . . . . . : 32637038 . 00 DATE ISSUED. . . . . . . : 10/05/2009 RECEIPT #. . . . . . . . . : BS000008840 REFERENCE ID # . . . 09100033 SITE ADDRESS . . . . . : 10268 CRESTON DR SUBDIVISION . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . OWNER . . . . . . . . . . . . : CHAMBERLAIN STEPHEN ADDRESS . . . . . . . . . . : 10268 CRESTON DR CITY/STATE/ZIP . . . : CUPERTINO CA, CA 95014-1014 RECEIVED FROM . . . . : STEPHEN T CHAMBERLA CONTRACTOR . . . . . . . : LIC # *OWNER* COMPANY . . . . . . . . . . : CHAMBERLAIN STEPHEN ADDRESS . . . . . . . . . . : 10268 CRESTON DR CITY/STATE/ZIP . . . : CUPERTINO CA, CA 95014-1014 TELEPHONE . . . . . . . . FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- ---------- 1BCBSC VALUATION 500. 00 1 . 00 0. 00 1. 00 0 . 00 1BSEISMICR VALUATION 500. 00 0 .50 0. 00 0 . 50 0 . 00 1EPERMITFE FLAT RATE 1 . 00 42 . 00 0. 00 42 . 00 0 .00 1ERT<200 UNITS 1 . 00 42 .00 0. 00 42 . 00 0 .00 1TRAVDOC FLAT RATE 1 . 00 42 .00 0 . 00 42 . 00 0 .00 ---------- ---------- ---------- ---------- TOTAL PERMIT 127 .50 0 . 00 127.50 0 . 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CREDIT CARD 127 . 50 VISA --------------- TOTAL RECEIPT 127 .50 0� 000 3-3 CITY OF CUPERTINO CUPEkTINO GENERAL BUILDING PERMIT APPLICATION FORM APN# —32 (J Date: ` 01� Building Address: (Oc2— 6 � ,yes &/o i? 6L.,ptr t� l Mailing Address (if different from building address): Are Hazardous Materials being used as part of this project? Yes 0 No HOA: (Exterior work only) Yes ❑ No If yes, provide letter from HOA Owner's Name: Phone#: e - r7 '7j - 3©y b Contractor: Phone: i 0 (.0 A-1-1V- Fax: Contractor License#: Cupertino Business License#: Contact: Phone: Fax: Residential Commercial Job Description. CAA-r ,� -e C>� EX lS / (A� ( Oc� /9/`v E-Ire /'f t ,-2 Building Permit Info: Bldg El Elect Plumb ElMech El Type of Construction (Usage Class): Occupancy Type: 1-A, 1-B ❑ II/III/V-A ❑ II/III B, IV-HT, V- Valuation: Square Footage: sem, o c Project Size: Express ❑ Standard ❑ Large ❑ Ma'or ❑ Green Building: Please complete relevant portion of the Green Building/LEED Checklist& attach it to the application or if applicable, include in plan set& the sheet index. Points Achieved: For help, contact Build it Green at www.buildit reen.or Revised 07/14/09 tat CITY OF CUPERTINO CU CITY Of O GENERAL BUILDING APPLICATION FEE SCHEDULE Quantity/Sf Fee ID Fee Description Fee Permit Type Group 1GENRES or 1GENCOM 1STUCOAP Stucco Applications (up to 400 sf) B additional stucco application 1 WINREP Replacement windows/sliding glass B door (ea 8 windows) 1 WINMEWSTR New Window-structural shear B wall/masonry(includes plan ck fee) 1 EPERMITFEE Electrical Permit Fee E 1MPERMITFEE Mechanical Permit Fee M 1PPERMITFEE Plumbing Permit Fee P 1 ELCPLNCK Stand Alone Electric Pln Ck (hourly) E 1 MECPLNCK Stand Alone Mechanical Pln Ck(hrly) M 1PLMBLNCK Stand Alone Plumbing Pln Ck (hrly) P 1 STPLNCK-(3 Hr Min Standard Plan Check (when no E/M/P) B when not over counter) hourly-stand alone 1BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT TYPES 1BSEISMICR Seismic Residential B 1BSEISMICO Seismic Commercial B 1TRAVDOC Travel &Documentation B 1BUSLIC Business License B Z 5 of 5