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11040044 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10470 SERRA ST CONTRACTOR:VOLTZ ELECTRIC PERMIT NO: 11040044 OWNER'S NAME: BART LAMMERSEN 6245 LEAN AVE DATE ISSUED:04/07/2011 OWNER'S PHONE: 4083645000 SAN JOSE,CA 95123 PHONE NO:(408)835.3866 LICENSED CONTRACTOR'S DECLARATIONF BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class ,. Lic.# Jl Z 3 7 Z MECH RESIDENTIAL COMMERCIAL ContractorVC- Z �i�.t G. Date�� I hereby affirm that I am licensed under the provisions o hapter 9 JOB DESCRIPTION:INSTALL DEDICATED CIRCUITS,RECEPTACLES FOR (commencing with Section 7000)of Division 3 of the Business&Professions FUTURE Code and that my license is in full force and effect. SUMP PUMPS,DEDICATED BRANCH CIRCUIT FOR CRAWL SPACE 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. C/ Sq.Ft Floor Area: Valuation:$900 APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is APN Number:34259011.00 Occupancy Type: 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, PERMIT EXPIRES IF WORK IS NOT STARTED costs,and expenses which may accrue against said City in consequence of the granting of this permit. Additionally,the applicant understands and will comply WITHIN 180 DAYS OF PERMIT ISSUANCE OR with all non-point source regulations per the Cupertino Municipal Code,Section 180 DAYS FROM LAST CALLED INSPECTION. 9.18. Signature Date113�L1 Issued b - Date: OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for one of RE-ROOFS: the following two reasons: All roofs shall be inspected prior to any roofing material being installed.If a roof is 1,as owner of the property,or my employees with wages as their sole compensation, installed without first obtaining an inspection,I agree to remove all new materials for will do the work,and the structure is not intended or offered for sale(Sec.7044, inspection. Business&Professions Code) 1,as owner of the property,am exclusively contracting with licensed contractors to Signature of Applicant: Date: construct the project(Sec.7044,Business&Professions Code). I hereby affirm under penalty of perjury one of the following three ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER declarations: I have and will maintain a Certificate of Consent to self-insure for Worker's HAZARDOUS MATERIALS DISCLOSURE 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 read the hazardous materials requirements under Chapter 6.95 of the I have and will maintain Worker's Compensation Insurance,as provided for by California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain Section 3700 of the Labor Code,for the performance of the work for which this compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health& Safety Code,Section 25532(a)should I store or handle hazardous material. permit is issued. Additionally,should I use equipment or devices which emit hazardous air I certify that in the performance of the work for which this permit is issued,I shall contaminants as defined by the Bay Area Air Quality Management District I will not employ any person in any manner so as to become subject to the Worker's maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the Compensation laws of California. If,after making this certificate of exemption,1 Health&Safety Code,Sections 25505,25533,and 25534. 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. Owne or authorized agent: 7 Date: 7 APPLICANT CERTIFICATION CONSTRUCTION LENDING AGENCY 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 I hereby affirm that there is a construction lending agency for the performance of work's to building construction,and hereby authorize representatives of this city to enter for which this permit is issued(Sec.3097,Civ C.) upon the above mentioned property for inspection purposes.(We)agree to save Lender's Name indemnify and keep harmless the City of Cupertino against liabilities,judgments, c- and expenses which may accrue against said City in consequence of the Lender's Address ng of this permit.Additionally,the applicant understands and will comply w....all non-point source regulations per the Cupertino Municipal Code,Section ARCHITECT'S DECLARATION 9.18. I understand my plans shall be used as public records. Signature Date Licensed Professional 121 CITY OF CUPERTINO FEE ESTIMATOR- BUILDING DIVISION ADDRESS: 10470 serra st DATE: 04/07/2011 REVIEWED BY: bobs. APN: BP#: "VALUATION: $900 'PERMIT TYPE: Electrical Permit PLAN CHECK TYPE: Alteration/Addition/ Repair PRIMARY SFD or Du lex PENTAMATION 1 REAP? USE: p PERMIT TYPE: WORK install dedicated circuits receptacles for future sump pumps,dedicated branch circuit for crawls ace SCOPE fan. APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Conduits 1BREMMISC 1 # $126 Recep/Switch/Outlets 1 BREMRECEP 4 # $42 TOTALS: 1 $168.00 Elec.Plan Check 0.0hrs $0.00 Elec.Permit Fee: IEPERMIT Other Elec.Insp. 0.0 hrs $42.00 NOTE: These ees are based on the preliminary information available and are only an estimate. Contact the De t or addn 7 info. FEE ITEMS (/'ee Resolution 09-051 IS-' "f,%0) FEE QTY/FEE MISC ITEMS PME Plan Check: $0.00 PME Unit Fee: $168.00 PME Permit Fee: $42.00 Work Without Permit? 0 Yes E) No $0.00 Travel Documentation Fee: ITRA VDOC $42.00 Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item Bldg Stds Commission Fee: 1BCBSC $1.00 1 1 SUBTOTALS: $253.50 $0.001 TOTAL FEE: 1 $253.50 Revised: 01/15/2011 CITY OF CUPERTINO 6 ITEMS OF 6 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN . . . . . . . . : 34259011. 00 DATE ISSUED. . . . . . . : 04/07/2011 RECEIPT #. . . . . . . . . BS000013120 REFERENCE ID # . . . : 11040044 SITE ADDRESS . . . . . : 10470 SERRA ST SUBDIVISION . . . . . . CITY . . . . . . . . . . . . . . CUPERTINO IMPACT AREA . . . . . . OWNER . . . . . . . . . . . . : BART LAMMERSEN ADDRESS . . . . . . . . . . : 10470 SERRA ST CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM . . . . : MATE SABICH JR CONTRACTOR . . . . . . . : MATT SABICH LIC # 31809 COMPANY . . . . . . . . . . : VOLTZ ELECTRIC ADDRESS . . . . . . . . . . : 6245 LEAN AVE CITY/STATE/ZIP . . . : SAN JOSE, CA 95123 TELEPHONE . . . . . . . . : (408) 835-3866 FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- ---------- 1BCBSC VALUATION 900. 00 1.00 0.00 1. 00 0.00 1BREMMISC EACH 1. 00 126. 00 0.00 126 .00 0.00 1BREMRECEP NO. OUTLETS 1 .00 42 . 00 0. 00 42 .00 0.00 1BSEISMICR VALUATION 900 .00 0.50 0. 00 0 .50 0. 00 1EPERMITFE FLAT RATE 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 253 .50 0.00 253 .50 0.00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CHECK 253 .50 #1537 --------------- TOTAL RECEIPT 253 .50 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 304 ROUGH ELECTRICAL 505 FINAL ELECTRICAL Building Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014-3255 Telephone: 408-777-3228 C U P E RT I N O Fax: 408-777-3333 CONTRACTOR/ SUBCONTRACTOR LIST JOB ADDRESS: -vv c, PERMIT# Q y OWNER'S NAME: Zwy, apleltei—e-nPHONE# GENERAL CONTRACTOR: Vb— BUSINESS LICENSE# ADDRESS: C q,l aull CITY/ZIPCODE: *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 SUB ONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE. I am not using any subcontractors: 7 �ti ZX 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 Owner/Contractor Signature Date //Cvooq� GENERAL PERMIT APPLICATION MEP COMMUNITY DEVELOPMENT DEPARTMENT- BUILDING DIVISION 10300 TORRE AVENUE-CUPERTINO, CA 95014-3255 (408)777-3228- FAX(408)777-3333-building crDcupertino.org MISC CUPERTINO ❑PLUMBING ❑MECHA/NICAL ECTRICAL / ❑MISCELLANNEOUS PROJECT ADDRESS CYvc / APN# // /� OWNER NAME P !76 ^ I D E-MALI, ll ✓ STREET ADDRESS CITY, STATE,ZIP FAX /0 V70 ✓✓ ` ( 1� CONTACT NAME / P ONE E-MAIL rFAX STREET ADDRESS '70 , , ❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT ❑!CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT CONTRACTOR NAI/ Z -- � LICENSE ZBER 7 LICENSE TYPE BUS.LIC# COMPANY NAME V E-MAIL ! FAC STREET ADDRESS C7,STA ZIP } G off ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC# COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE USE OF FD or Duplex ❑ Multi-Family PROJECT IN WILDLAND PROJECT IN STRUCTURE: ❑ Commercial URBAN INTERFACE AREA ❑ Yes ❑ No FLOOD ZONE ❑ Yes ❑ No DESCRIPTION OF WORK 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 p vided is correct. I 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 b Idin construction. I authorize representatives of Cupertino to enter the above-identified property for inspection purposes. Signature of Applicant/Agent: Date: PLEMENTAL INFORMATION REQUIRED FMCKUS s, '� I f7VFR T$I'x�OTAW`FY':I>c ' - ;E�EPRES& a �'R1c' ?Q�S,TAI`IDAiRIh `' QA;)57AJdit. MEPMiscApp_2011.doc revised 03/16/11