09120066 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 903 BROOKGROVE LN CONTRACTOR:JOCAL ELECTRIC PERMIT NO:09120066
OWNER'S NAME: SMITH FRANK M AND PAM 6145 CAHALAN AVE DATE ISSUED: 12/10/2009
ER'S PHONE: 4082579542 SAN JOSE,CA 95123 PHONE NO:(408)912-5205
❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG I— ELECT r PLUMB f—
License Class Lic.#
MECH T_ RESIDENTIAL f- COMMERCIAL
Contractor Date
I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION: SERVICE UPGRADE TO 200AMP
(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:$2500
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
permit is issued. APN Number:37539023.00 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 po4kpoint source regulations per the Cupertino Municipal Code,Section Issued by: Date:
9.18. /
Si / r �Inq�-4Date 1 L'
RE-ROOFS:
Cl 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
1 hereby affirm that I am exempt from the Contractor's License Law for one 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)
1,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 following three HAZARDOUS MATERIALS DISCLOSURE
declarations: I have read the hazardous materials requirements under Chapter 6.95 of the
1 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
permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
p 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'sner ora orize nt:
Compensation laws of California. If,after making this certificate of exemption,I Date:L:410019
become subject to the Worker's Compensation provisions of the Labor Code,I mustl_/--X/Y T\,�- — - --L,—I
forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of work'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
nify and keep harmless the City of Cupertino against liabilities,judgments, ARCHITECT'S DECLARATION
and expenses which may accrue against said City in consequence of the
granting of this permit.Additionally,the applicant understands and will comply I understand my plans shall be used as public records.
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18. ^ C� Licensed Professional
Signage
I J Date"L
y �
ITY F 1� PE � l 2 u
C O ..'U RTINO
CUPE(�TINO GENERAL BUILDING
PERMIT APPLICATION FORM
APN # _ , Date:
-3
-3 . 9//S/a
Building Address: 903 �� O
Mailing Address (if different from building add s):
Are Hazardous Materials being used as part of this. project? Yes No ET
HOA: Exterior work only) Yes ❑ No [J If yes, provide letter from HOA
Owne 's Name: Phone#:
Contractor: Phone:
oC.ci 0 echp" C q Fax:
Contractor License#:
Cupertino Business License#:
Contact: Phone: y og -791 -6 9.5
Fra h C H Fax: ,--
Residential 0 Commercial ❑
Job Description: +o ::200 A
S Iry i ce ilgrac� �
Building Permit Info:
Bldg 3-- Elect ❑`---- Plumb ❑ Mech ❑
Type of Construction (Usage Class): Occupancy Type:
1-A, 1-B ❑ II/III/V-A ❑ II/III B, IV-HT, V-B �L— J
Valuation: Square Footage:
Project Size: Express0,--Standard ❑ Large [] Major ❑
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.builditereen.or
Revised 07/14/09
CITY OF CUPERTINO
attz�
GENERAL BUILDING APPLICATION
CUPEI�TINO
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
1WINREP Replacement windows/sliding glass B
door (ea f> windows)
1 WINMEWSTR New Window-structural shear B
wall/mascnry (includes plan ck fee)
1 EPERMITFEE Electrical Permit Fee E
1MPERMITFEE Mechanical Permit Fee M
1PPERMITFEE Plumbing Permit Fee P
IELCPLNCK Stand Alcne Electric Pln Ck(hourly) E
1 MECPLNCK Stand Alcne Mechanical Pln Ck(hrly) M
1PLMBLNCK Stand Alcne Plumbing Pln Ck(hrly) P
1 STPLNCK-(3 Hr Min Standard Nan Check (when no E/M/P) B
when not over counter) hourly-st"nd alone
1BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT
I TYPES
1BSEISMICR Seismic F.esidential B
1BSEISMICO Seismic Commercial B
1 TRAVDOC Travel & Documentation B
1BUSLIC Business License B
�� "�� 5of5