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11040151 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 21087 GRENOLA DR CONTRACTOI ' ERMIT NO: 11040151 OWNER'S NAME: FLOYD ADAMS DATE ISSUED:04/21/2011 OWNER'S PHONE: 4082537424 PHONE NO: L LICENSED CONTRACTOR'S DECLARATION9 BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class Lie.# Z �/ `' MECH RESIDENTIAL COMMERCIAL r S �rlr Date Contracto I hereby affirm that I am lice se do r he-provisions of Chapter 9 JOB DESCRIPTION:UPGRADE 1 EXISTING MAIN PANEL TO 125AMPS&ADD 1 (commencing with Section 7000)of Division 3 of the Business&Professions 70AMP SUBPANEL AT BEDROOM LOCATION 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. 1 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.Ft Floor Area: Valuation:$2300 permit is issued. APPLICANT CERTIFICATION ';/4w APN Number:32628008.00 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 upon the above mentioned property for inspection purposes. (We)agree to save PERMIT EXPIRES IF WORK IS NOT STARTED indemnify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City in consequence of the WITHIN 180 DAYS OF PERMIT ISSUANCE OR granting of this permit. Additionally,the applicant understands and will comply 180 DAYS FROM LAST CALLED INSPECTION. with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. 4 Issued by:/' Date: C-9 Signatur �-•-� 8atc r OWNER-BUILDER DECLARATION RE-ROOFS: I hereby affirm that I am exempt from the Contractor's License Law for one of All roofs shall be inspected prior to any roofing material being installed.If a roof is the following two reasons: installed without first obtaining an inspection,I agree to remove all new materials for 1,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 Applicant: Date: 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 declarations: HAZARDOUS 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 Health&Safety 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 Health& Section 3700 of the Labor Code,for the performance of the work for which this Safety Code,Section 25532(a)should I store or handle hazardous material. Additionally,should I use equipment or devices which emit hazardous air permit is issued. contaminants as defined by the Bay Area Air Quality Management District I will I certify that in the performance of the work for which 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's Health&Safety Code,Sections 25505,25533,and 25534. 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 O e r au nt forthwith comply with such provisions or this permit shall be deemed revoked. Date: l APPLICANT CERTIFICATION CONSTRUCTION LENDING AGENCY I certify that I have read this application and state that the above information is I hereby affirm that there is a construction lending agency for the performance of work's correct.I agree to 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 co- and expenses which may accrue against said City in consequence of the ig of this permit.Additionally,the applicant understands and will comply ARCHITECT'S DECLARATION w....all non-point source regulations per the Cupertino Municipal Code,Section 9.18. 1 understand my plans shall be used as public records. Signature Date Licensed Professional CITY OF CUPERTINO 5 ITEMS OF 6 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN . . . . . . . . : 32628008. 00 DATE ISSUED. . . . . . . : 04/21/2011 RECEIPT 4. . . . . . . . . : BS000013254 REFERENCE ID # . . . : 11040151 SITE ADDRESS . . . . . : 21087 GRENOLA DR SUBDIVISION . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . . OWNER FLOYD ADAMS ADDRESS 21087 GRENOLA DR CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM . . . . : FLOYD W ADAMS CONTRACTOR . . . . . . . : TBD - TO BE DETERMINED LIC # 00096 COMPANY . . . . . . . . . . : TBD - TO BE DETERMINED ADDRESS . . . . . . . . . . CITY/STATE/ZIP . . . : , TELEPHONE . . . . . . . . FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- ---------- 1BCBSC VALUATION 2, 300 . 00 1. 00 0.00 1.00 0. 00 1BSEISMICR VALUATION 2, 300 .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 2 . 00 84 .00 0. 00 84 .00 0. 00 1TRAVDOC FLAT RATE 1 .00 42. 00 0.00 42 .00 0.00 ---------- ---------- ---------- ---------- TOTAL PERMIT 169. 50 0. 00 169.50 0. 00 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 103 UFER 304 ROUGH ELECTRICAL 505 FINAL ELECTRICAL CITY OF CUPERTINO FEE ESTIMATOR- BUILDING DIVISION ADDRESS: 21087 granola dr. DATE: 04/21/2011 REVIEWED BY: bobs. APN: BP#: "VALUATION: 1$2,300 Y PERMIT TYPE: Electrical Permit PLAN CHECK TYPE: Alteration /Addition/ Repair PRIMARY SFD o Du lex PENTAMATION 1 REAP2 USE: p PERMIT TYPE: WORK upgrad"Asting main panel to 125 ams add 70 amp subpanel at bedroom location. SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Services 1 ERT<200 125 Amps $42 Services 1 ERT<200 70 Amps $42 TOTALS. $84.00 Elec.Plan Check 0.0 1 hrs $0.00 Elec.Permit Fee: IEPERMIT Other Elec.Insp. Ej hrs $42.00 NOTE. These fees are based on the preliminary information available and are only an estimate. Contact the Dept-for addh 7 info, FEE ITEMS (T'ee Resolution 09-05.1 ].!1, TT`10) FEE QTY/FEE MISC ITEMS PME Plan Check: $0.00 FT PME Unit Fee: $84.00 PME Permit Fee: $42.00 Work Without Permit? 0 Yes E) No $0.00 Travel Documentation Fee: ITRA VDOC $42.00 Strony,Motion Fee: IBSEISMICR $0.50 0.5 hrs Admin./Clerical Fee Bldg,Stds Commission Fee: IBCBSC $1.00 $39.00 /ADMIN SUBTOTALS: $169.50 $39.00 TOTAL FEE: $208.50 Revised: 04/01/2011 Building Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014-3255 Telephone: 408-777-3228 U P E RT I N O Fax: 408-777-3333 CONTRACTOR/ SUBCONTRACTOR LIST JOB ADDRESS: `� , PERMIT# So'/ OWNER'S NAME: S PHONE# GENERAL CONTRACTOR: _ BUSINESS LICENSE# ADDRESS: &e 7 `/~E � CITY/ZIPCODE: '��Ptry *Our municipal code requires all businesses working in the city to have a City of Cuper ino 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. 7 1 am not using any subcontractors: Signature Date Please check applicable subcontractors and complete the following 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 GENERAL PERMIT APPLICATION MEP COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 Lo (408)777-3228 • FAX(408)777-3333•building 5cupertino.org misc CUPERTINO ❑PLUMBING ❑MECHANICAL ELECTRICAL ❑^MISCELLANEOUS f�Z /- PROJECT ADDRESS ` D APN# C cl n g OWNER.NAME _-MAIL, STREET ADDRESS r _ Cl1_Y.STATE.ZIP �`1; 1-41 FAX CONTACT NAME P _ L E-MAIL STREET ADDRESS ATE.ZIP FAX r2214 OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT CONTRACTOR NAM4-1'b/ 1 LICENR LI E TYP BUS.LIC# COMPANY NAME E-MAIL FAX STREETADD S CPIY TATE,ZIP. P O E �� l 7 J J ARCHMMENGINEER NAME LICENSE NUMBER BUS.LIC# COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE TSE OF ErSfE­or Duplex ❑ Multi-Family PROJECT IN WILDLAND PROJECT IN STRUCTURE: ❑ Commercial URBAN INTERFACE AREA ❑ Yes ❑ No FLOOD ZONE ❑ Yes ❑ No DESCRIPTION OF WORK TOTAL VALUATION: JJ4 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. I have read the Description of Work and verify it is accurate. I agree to compiv with all applicable local ordinances and state laws relating to bui ing constructi n. I authorize representatives of Cupertino to enter the above-idtified pro / for inspection purposes. Signature of Applicant/Agent: — �� Date: SUPPL NTAL INFORMATION REQUIRED �il�t€ rsr�a� MEPMiscA,pp_201 Ldoc revised 03/16/11