13030084 (2) CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10092 MANN DR CONTRACTOR: PERMIT NO:13030084
tie,.
OWNER'S NAME: DENNIS WIANTMAN DATE ISSUED:03/15/2013
OWNER'S PHONE: 4083202392 PHONE NO:
LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL 11 COMMERCIAL11
License Class C 10 Lie.# Q"� gj3J 'G REPLACE(E) 100 AMP EL PANEL,SAME LOCATION
Contractor Date 17
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:$1500
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 APN Number:32419004.00 Occupancy Type:
permit is issued.
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED
correct.I agree to comply with all cityand,00unty ordinances and state laws relating WITHIN 180 DAY-SX IT ISSUANCE OR
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save 180 DAY LAS LIED INSPECTION.
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the , S
granting of this permit. Additio 11 the
the applicant understands and will comply ssued by:
with all non-point source reg ons per the Cupertino Municipal Code,Section
9.18.
RE-ROOFS:
Signature \ Date r— 13 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
inspection.
❑ OWNER-BUILDER DECLARATION
Signature of Applicant: Date:
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
1,as owner of the property,or my employees with wages as their sole compensation,
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 HAZARDOUS MATERIALS DISCLOSURE
construct the project(Sec.7044,Business&Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the
California Health&Safety Code,Sections 25505,25533,and 25534. 1 will
I hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
declarations: Health&Safety Code,Section 25532(a)should I store or handle hazardous
I have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally,should I use equipment or devices which emit hazardous
Compensation,as provided for by Section 3700 of the Labor Code,for the air contaminants as defined by the Bay Area X, m
lity Management District I
performance of the work for which this permit is issued. will maintain compliance with the Cupertinopal Code,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sections 255 5,25 25534.
Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agent: Date:
permit is issued.
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's
Compensation laws of California. If,after making this certificate of exemption,I CONSTRUCTION LENDING AGENCY
become subject to the Worker's Compensation provisions of the Labor Code,I must I hereby affirm that there is a construction lending agency for the performance of
forthwith comply with such provisions or thi&permit shall be deemed revoked. work's for which this permit is issued(Sec.3097,Civ C.)
Lender's Name
APPLICANT CERTIFICATION Lender's Address
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 ARCHITECT'S DECLARATION
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records.
granting of this permit.Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section Licensed Professional
9.18.
Signature Date
GENERAL PERMIT APPLICATION 5
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION D
MEP
.10300 TORRE AVENUE•CUPERTINO,CA 95014-3255
CEJPERTIFfO
(408)777-3228•FAX(408)777-3333• building cDcuoerto
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❑PLUMBING ❑MECHANICAL EKLECTRICAL ❑MISCELL.ANEOUS
PROJECT ADDRESS OAPN: � -GOD
OWNER NAME �, /✓/S I l " �j Zo —2,3f 2 E-WiL
STREET ADDRESS G CITY, STATE,ZIP FFAX
CONTACT NAME ` T Z PHONE / rQ�Z FMAILV/1M,(a'fy
STREETADDR22 AM , `CITY.STATE,ZTPt)4LjfCAgr70FAX
13OWHIER .•❑ OW1dER.BUILDER ❑ OWNERAGENT WICIZACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT
COI•�TRACTOR NAME K`.t �`L C ^ LICENSE NUMBE 7TSE TYPE I BUS.LIC;#
COMPANY NAME K11 1WS 7r{CIL/ lG' E-MAIL
MAS K o gS FAX
STREET ADDRESS2Z071+
ZO 1+ S ^ Y CTCV,STATE,ZIP WAL11(�L C* V?(7(B�t'J� PHONE
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ARCHTCECT/ENGIEER NAME C' LICENSE NUMBER T BUS.LIC##
COMPANY NAME' E-MAIL, FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF SFD or DUPLEX ❑ MULTI-FAMILY PROJECT IN WILDLAND ❑ YES PROJECT IN YES IS THE BLDG AN ❑YES
BUILDING: ❑COM'MERCIAL URBAN INTERFACE AREA NO FLOOD ZONE O EICHLER HOME? O
DESCRIPTION OF WORK �Q e `
TOTAL VALUATION: O RECEIVED BY:
By my signature below,I certify to each of the following: the property owner or authorized agent to act on the property owner's behalf. I have read this
application and the information I have prop ided i correc I ave read the Description of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating to building co cti authorize representatives of Cupertino to enter the above-identified propci&for inspection putposes.
Signature of Applicant/Agent: x ` Date: A 3 (57— l
SUPPLEMENTAL INFORMATION REQUIRED OFFICE USE ONLY
OVER-THE COUNTER
EXPRESS
U
❑ STANDARD
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❑ LARGE
❑ MAJOR
MEPA&cApp 2011.doc revised 06121/11
CITY OF CUPERTINO
FEE ESTIMATOR—BUILDING DIVISION
ADDRESS: 10092 Mann Dr DATE: 03/15/2013 REVIEWED BY: Sean
APN: BP#: *VALUATION: 1$1,500
*PERMIT TYPE: Electrical Permit PLAN CHECK TYPE: Alteration/Addition/ Repair
PRIMARY SFD or Duplex PENTAMATION 1 REAP
USE: PERMIT TYPE:
WORK Remove and re lace main electrical service 100 amp).
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Services JBELEC200100 Amps $45
TOTALS: $45.00
{
Leech.Flan Check Phimb,Plan Check EIeC.Plan Check 0.0 hrs $0.00
L1echlle mit Fee. Plumb.Permit ree: Elec.Permit Fee: 1EPERMIT
t)ther,11ech.Insp. tither Plumb Insp. Other Elea Insp. 0.0 hrs $45.00
:Rech.Insp.Fee. Plumb. Insp.Fee: Elec.Insp.Fee:
NOTE:This estimate does not include fees due to other Departments(ie.Planning,Public Works,Fire,Sanitary Sewer District,School
District,etc). Theseees are based on the pralimina information available and are only an estimate. Contact the Dept for addn7 info,
FEE ITEMS(Fee Resolution 11-053 E . 711112) FEE QTY/FEE MISC ITEMS
Plan Cheek 1,'ee:
suppl. PC F"ce
PME Plan Check: $0.00
Permit.Fee:
Suppl. Insp I ee
PME Unit Fee: $45.00
PME Permit Fee: $45.00
Construction Tax:
Administrative Fee: IADAHN $42.00
Work Without Permit? 0 Yes (E) No $0.00
Advanced Planning Fees:
Travel Documentation Feer 1TRAVDOC $45.00
Strong Motion Fee: 1BSEISMICR $0.50 Select an Administrative Item .
Bldg Stds Commission Fee: IBCBSC $1.00
$178.50 $0.00 $178.50
Revised: 01/01/2013