11060183 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10042 MOSSY OAK CT CONTRACTOR:JANET ESAKENAZI PERMIT NO: 11060183
OWNER'S NAME: JANET ESAKENAZI 10042 MOSSY OAK CT DATE ISSUED:06/21/2011
OWNER'S PHONE: 4082532117 CUPERTINO,CA 95014-5615 PHONE NO:
G LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ELECT PLUMB r
License Class Lic.#
MECH RESIDENTIAL(_ COMMERCIAL
Contractor Date
JOB DESCRIPTION:ELECTRICAL SERVICE CHANGE OUT 100AMP
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. Sq.Ft Floor Area: Valuation:$1600
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. APN Number:34232108.00 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 PERMIT EXPIRES IF WORK IS NOT STARTED
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save WITHIN 180 DAYS OF PERMIT ISSUANCE OR
indemnify and keep harmless the City of Cupertino against liabilities,judgments, 180 DAYS FROM LAST CALLED INSPECTION.
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 Issued by:_ � - Date: U/ ``J
9.18.
Signature Date
1 RE-ROOFS:
OWNER-BUILDER DECLARATION 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
I hereby affirm that I am exempt from the Contractor's License La ne of inspection.
the following two reasons:
1,as owner of the property,or my employees with wages as their sole compensation, Signature of Applicant: Date:
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 ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
construct the project(Sec.7044,Business&Professions Code).
I hereby affirm under penalty of perjury one of the followin t WHAZARDOUS MATERIALS DISCLOSURE
declarations: ! 1 have read the hazardous materials requirements under Chapter 6.95 of the
I have and will maintain a Certificate of Consent to self-insure for Worker's California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain
Compensation,as provided for by Section 3700 of the Labor Code,for the compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
performance of the work for which this permit is issued. Safety Code,Section 25532(a)should I store or handle hazardous material.
I have and will maintain Worker's Compensation Insurance,as provided for by Additionally,should I use equipment or devices which emit hazardous air
Section 3700 of the Labor Code,for the performance of the work for which this 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
permit is issued. Health&Safety Code,Sections 25505,25533,and 25534.
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'sp er t ri ed
Compensation laws of California. If,after making this certificate of exemption,I Date:� ) 6 b
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. CO TRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of wrk's
APPLICANT CERTIFICATION for which this permit is issued(Sec.3097,Civ C.)
I certify that I have read this application and state that the above information is Lender's Name
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 Lender's Address
upon the above mentioned property for inspection purposes.(We)agree to save
indemnify and keep harmless the City of Cupertino against liabilities,judgments, ARCHITECT'S DECLARATION
C, and expenses which may accrue against said City in consequence of the
L rg of this permit.Additionally,the applicant understands and will comply I understand my plans shall be used as public records.
witu all non-point source regulations per the Cupertino Municipal Code,Section
9.18. Licensed Professional
Signatur ��"� Date 14t 1)
CITY OF CUPERTINO
FEE ESTIMATOR- BUILDING DIVISION
F[
ADDRESS: 10042 mossy oak ct. 1 DATE: 06/21/2011 REVIEWED BY: bobs.
APN: BP#: 'EVALUATION: $1,600
'PERMIT TYPE: Electrical Permit PLAN CHECK TYPE: Alteration /Addition/ Repair
PRIMARY PENTAMATION 1 REAP2
USE: SFD or Duplex PERMIT TYPE:
WORK electrical service change out 100 am
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Services 1 ERT<200 100 Amps $42
-T-
TOTALS: $42.00
Elec.Plan Check0.0 hrs $0.00
Elec.Permit Fee: IEPERMIT
Other Elec.Insp. 0.0 hrs 1 $42.00
NOTE: These fees are based on the preliminary in ormation available and are onlE an estimate. Contact the Dept for addn'l info,
FEE ITEMS (Pee Resolution fit)-OS! lsff' ','l.-"/D) FEE QTY/FEE MISC ITEMS
PME Plan Check: $0.00
PME Unit Fee: $42.00
PME Permit Fee: $42.00
Work Without Permit? 0 Yes (j) No $0.00
Travel Documentation Fee: 1 TRA VDOC $42.00
Stronfz Motion Fee: IBSEISMICR $0.500.5 hrs Admin./Clerical Fee
Bldg Stds Commission Fee: 1BCBSC $1.00 $39.00 IADAffN
SUBTOTALS: $127.50 $39.00 TOTAL FEE: $166.50
Revised: 04/29/2011
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GENERAL PERMIT APPLICATIONMEP
COMMUNITY DEVELOFMENT DEPARTMENT- BUILDING DIVISION
10300 TORRE AVENUE - CUPERTINO, CA 95014-3255
- (408)777-3228 - FAX(408)777-3333 •building(Qcupertimc.org
UPERTlN4 misc
❑PLUMBING ❑MECHANICAL I ELECTRICAL ❑MISCELLANEOUS
PROJECT ADDRESS [ 004_.) i'yl '_J_ � O I APN 1 i� /'
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OWNER NAME — �'ti'l f 1('31'L
STREET ADDRESS j l L� E-MA'L�J
JiVI �`�.e�.►1r�2� �,�Sl�e �V'r1�_ �r!�'rr1YYY'►
Ido i)� l V VL CITY,STATE,
CONTACT NAME PHONE E-MXZM
STREET ADDRESS CITY,STATE, ZP FAX
U101" C2OWNER-au=ER ❑ OWNER>AGENT ❑ CONTRACTOR ❑CONTRAGTOP AGENT ❑ ARaCrECC ❑ENGMEER ❑ DEVELOPER ❑TENANT
CONTRACTOR NAMELICENSE NUMBER. LICENSE TYPE HUS.LIC N
2-1
COMPANY NAME � L E-NUUL / FAX C" t
STREET ADDRESS n CITYZ,STATE ZIP �' PHONE
ARCI=CT/ENGINEE&R NAME LICENSE NUMBER BUS.LIC 4
COMPANY NAME E-MAL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
OF Duplex [IMulti-Family
ar PROJECT IN WILDLAND PROJECT IN
STRUCTURE: ❑ CO=ercial URBAN INTERFACE AREA ❑ Yes ❑ NO FLOOD ZONE ❑ Yes ❑ NO
DESCRIPTION OF WORK `
TOTAL VALUATION: 'F-T =-- a� m
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 comply with all applicable local
ordinances and state laws relating to buildingy, on. I authorize representatives of Cupertino to enter the above-identified property for inspection purposes.
Signature of Applicant(Agent/ Data: 'C
STVPLElVEEZ47AL INFO N REQU M ED
a a
dIEPMzrcApp_ZOl Ldac revised 03/16/11