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11100092 (2) CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 11245 MT CREST PL CONTRACTOR:VOLTZ ELECTRIC PERMIT NO: 11100092 OWNER'S NAME: GARY NEWMAN 6245 LEAN AVE DATE ISSUED: 10/13/2011 Oi 4ER'S PHONE: 6508678038 SAN JOSE,CA 95123 PHONE NO:(408)835-3866 L LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG f— ELECT PLUMB r License Class Lic.# $07Z / MECH RESIDENTIAL COMMERCIAL Contractor ✓0`�6 Date JOB DESCRIPTION:NEW BRANCH CIRCUIT FOR A FUTURE SUMP PUMP I hereby affirm that I am licensed under the provisions of hapter 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:$300 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:35626009.00 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 oint source regulations per the Cupertino Municipal Code,Section Issued by: Date: 9.18. Signat a Date !� "` 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 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) 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 following three HAZARDOUS MATERIALS DISCLOSURE declarations: I 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. 1 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's Own uthorized a ent: / Compensation laws of California. If,after making this certificate of exemption,I Date: 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. 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 indemnify and keep harmless the City of Cupertino against liabilities,judgments, ARCHITECT'S DECLARATION cr and expenses which may accrue against said City in consequence of the ig of this permit.Additionally,the applicant understands and will comply I understand my plans shall be used as public records. wiui all non-point source regulations per the Cupertino Municipal Code,Section 9.18. Licensed Professional Signature Date vv � GENERAL PERMIT APPLICATION MEP COMMUNITY DEVELOPMENT DEPARTMENT-BUILDING DIVISION 10300 TORRE AVENUE-CUPERTINO, CA 95014-3255 2 (408)777-3228 - FAX(408)777-3333- buildingQcupertino.org MISC CUPERTINO ❑PLUMBING ❑MECHANICAL ECTRICAL ❑MISSCE/LLANEOUS PROTECT ADDRESS rv1 APN* j o OWNER NAME PI�r — EMAIL STREET ADDRESS/Zvs �`t C STATE,ZIP FAX CONTACT NAME ' / PHO „ E-MAIL STREETADDRESSi/� STATE, ZIP FAX ❑ OWNER ❑ OWNER-BUILDER ❑ OWNERAGENT <.sC NTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT CONTRACTOR NAME + LICENSE NUMBER LI SE TYPE BUS.LIC# COMPANY NAME AE-MAIL FAX 4 �L STREET ADDRESS Z t��6{� /�`h CITY, TATE 4 - PHONE ARCHTI'ECTIENGINEER NAME i LICENSE NUMBER BUS.LIC# COMPANY NAME' E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE TSE OF SFD or DUPLEX ❑ MULTI-FAMILY PROTECT IN WIIALAND ❑ YES PROJECT IN ❑YES IS THE BLDG AN ❑YES BUILDING: ❑COMMERCIAL URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑NO IICHLER HOME? ❑NO DESCRIPTION OF WORK TOTAL VALUATION: 7o v .V RECEIVED BY: By my signature below,I certify to each a 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 vided is correct j 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 i] 'ng construction.`I uthorize representatives of Cupertino to enter the above-identified property for inspection pudposes. Signature of Applicant/Agentj' Dom: l �� S PLEMENTAL INFORMATION REQUIRED OFFIc E USE ONLY ❑ OVER-THE-COUNTER ❑ EXPRESS Y U w ❑ STANDARD T U Z ❑ LARGE a ❑ MAJOR MHPMiscApp 2011.doc revised 06/21111 CITY OF CUPERTINO FEE ESTIMATOR- BUILDING DIVISION ADDRESS: 11245 mt.crest place DATE: 10/13/2011 REVIEWED BY: bobs. APN: BP#: "VALUATION: $300 PERMIT TYPE: Electrical Permit PLAN CHECK TYPE: Alteration/Addition/ Repair PRIMARY SFD or Duplex PENTAMATION 1 REAP10 USE: p PERMIT TYPE: WORK new branch circuit for a future sump pump. SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Recep/Switch/Outlets 1BREMRECEP 1 # $44 TOTALS: $44.00 77 T Elec.Plan Check 0.0 hrs $0.00 Elec.Permit Fee: IEPERMIT Other Elec.Insp. L2-0jhrs $44.00 NOTE: This estimate does not include fees due to other Departments(i.e.Planning,Public Works,Fire,Sanitary Sewer District,School District,etc. . Thesefees are based on the prelinina information available and are only an estimate. Contact the De t or addn'l info, FEE ITEMS (1-ee Resolution 11-053 L f ?%1;''IIL FEE QTY/FEE MISC ITEMS PME Plan Check: $0.00 PME Unit Fee: $44.00 PME Permit Fee: $44.00 F71 Administrative Fee: IADMIN $41.00 Work Without Permit? 0 Yes 0 No $0.00 Travel Documentation Fee: ITRA VDOC $44.00 Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $1.00 SUBTOTALS: $174.501 $0.00 TOTAL FEE: $174.50 Revised: 10/01/2011 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: IV2 V5 /Ej . Gill Z PERMIT# `-� � `J OWNER'S NAME: PHONE# rS S-3 d GENERAL CONTRAC OR: p ;c BUSINESS LICENSE# ADDRESS: J�ZYr L 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: 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