11010076 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 11640 REGNART CANYON DR CONTRACTOR:POWER PLUS PERMIT NO: 11010076
SOLUTIONS CORP
OWNER'S NAME: JANET DECARLI 1210 RED GUM AVE DATE ISSUED:01/13/2011
,NER'S PHONE: 4082572100 ANAHEIM,CA 92806 PHONE NO:(714)765-7551
❑ LICENSED QQN'TRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ELECT r— PLUMB
License Class G /0 Lic.# 93-2 3 3Q MECH f— RESIDENTIAL f— COMMERCIAL
Contractor P/Z:s Date �
JOB DESCRIPTION: TEMP POWER FOR CELL SITE
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:$5459
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:36633006.00 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 city and county ordinances and state laws relating WITHIN 180 DAYS OF PERMIT 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 DAYS FROM LAST CALLED 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 Issued by: Date:
granting of this permit. Additionally,the applicant understands and will comply
with all non-point source regulations per th Cupertino Municipal Code,Section
9.18.
RE-ROOFS:
Signature
11-41-0, Date 13�-riG 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 Date:
Signature of Applicant:
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
I,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)
HAZARDOUS MATERIALS DISCLOSURE
1,as owner of the property,am exclusively contracting with licensed contractors to
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. I 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 Air Quality Management District I
performance of the work for which this permit is issued. will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by
the Health&Safety Code,Sections 25505,25533,and
Section 3700 of the Labor Code,for the perfonnance 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 CONSTRUCTION LENDING AGENCY
Compensation laws of California. If,after making this certificate of exemption,I
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 this 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
-non the above mentioned property for inspection purposes.(We)agree to save ARCHITECT'S DECLARATION
demnify 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
CITY OF CUPERTINO
6 ITEMS OF 6 PERMIT RECEIPT OPERATOR: SylviaM
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot :
APN 36633006 . 00
DATE ISSUED. . . . . . . : 01/13/2011
RECEIPT #. . . . . . . . . BS000012471
REFERENCE ID # . . . : 11010076
SITE ADDRESS 11640 REGNART CANYON DR
SUBDIVISION . . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : JANET DECARLI
ADDRESS . . . . . . . . . . : 11640 REGNART CANYON DR
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014-4830
RECEIVED FROM . . . . : POWER PLUS
CONTRACTOR . . . . . . . : SR BRAY LIC # 31429
COMPANY . . . . . . . . . . : POWER PLUS SOLUTIONS CORP
ADDRESS . . . . . . . . . . : 1210 RED GUM AVE
CITY/STATE/ZIP . . . : ANAHEIM, CA 92806
TELEPHONE (714) 765-7551
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- --
1BCBSC VALUATION 5, 459 . 00 1 . 00 0 . 00 1 . 00 0 . 00
1BSEISMICR VALUATION 5,459 . 00 0 . 55 0 . 00 0 .55 0 . 00
1BUSLIC FLAT RATE 1 . 00 115 . 00 0 . 00 115 . 00 0 . 00
1EPERMITFE FLAT RATE 1 .00 42 . 00 0 . 00 42 . 00 0 . 00
1ERT<200 UNITS 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 242 . 55 0 . 00 242 . 55 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- ------------------
CHECK 242 . 55 1176
---------------
TOTAL RECEIPT 242 . 55
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- --------
402 TEMPORARY POWER
CITY OF CUPERTINO
FEE ESTIMATOR—BUILDING DIVISION
ADDRESS: 11640 Regnart Canyon DATE: 01/13/2011 REVIEWED BY: jsg
191APN: I BP#: *VALUATION: $0
*PERMIT TYPE: Minor Building Permit PLAN CHECK TYPE: Temporary Power
PR1.VAR)' PENTAMATION 1 CEAP 14
S : Commercial BuildingF PERMIT TYPE:
WORK temp power pole for cell site work
SCOPE
APPLIANCE/EQUIP TYPE FEE ID AMPS VOLTS BP FEES
Service(incl.Temp. Power) 1 ECT<200 100 <=600 $42
:alt tit. 1-,11"m t hc'r'k
FT,
:is. 1'c�rr,r Fc>t>, rill>. 1' •-07it t't°-: FElec.Permit Fee: IEPERMIT
Ofi 11 7,, Ir,", t?the�r°P`t r,2T;iYrs1>- E]--1- C>t1t P 1�1<c.lush. 3--t $42.00
1Icch. Ij;.;p. I a< P.`Timb, how. Fcc' 11<c lPrsp. 11,10,- 1
NOTE: Theseees are based on the relimina in ormation available and are onlyan estimate. Contact the De t or addn'l info.
FEE ITEMS(Fee Resolution 09-051 Ejf. 7i1;70) FEE QTY/FEE MISC ITEMS
Plan C.'{tack Fee:
Supp/. 1'C1,lee
f'lzzrrz/z.;`ilefcTa. l;lec:Plan (''eek:
Permit Fe>c.
Supp/. Irisp Fe'e
PME Unit Fee: $42.00
PME Permit Fee: $42.00
C onswueiion Tax
,'Ic ouslic al Rc iTic iv
Work Without Permit? 0 Yes E) No $0.00
Plano-lin", Fces:
Travel Documentation Fee: ITRAVD0C $42.00
Stront; 'Votion Fee: Select an Administrative Item
B1dyStds Commission Fee: $0.00
SUBTOTALS: $126.00 $0.00 TOTAL FEE: $126.00
Revised: 01/03/2011
CI'T'Y OF
s
CITY OF CUPERTINO
TEMP POWER
CUPERTINO PERMIT APPLICATION FORM
APN # U ow, Date: I f
OL) l
Building Address: VD-140
rCAN!�()
Owner's NamZLIAVIt
- ( Phone #�os
Contractor:?0VWr
� Phone #: L1((1 05.107 3
�a-10 �. (OU �j'�. I�1�1QVlR.t 1�/l �,�,ol 6 Fax#: C .0-151 1' ,21
Contact: 1 �v c „ 1��e� 6
1 Phone #11(0.OD22. ,o ll3
Contractor License #: q 3jri 721po
Cupertino Business License #:
Job Description: ,nn ?OCQ reN St[L W W
.07
4-
Residential El Commercial
Valuation (cost of project): r ,1 r 05 .� Type of Construction: N/A
Quantity Fee ID Fee Description Fee Group Permit Type
lERT<200 Res. Temp Power<200 E 1REAP14
Amps
1 ERT2001 K Res. Temp Power 200-1 K E
Amps
lEPERMITFE Electric Permit Issuance
1BCBSC Cal Bldg Standards B ALL PERMIT
Commission Fee TYPES
1BSEISMICR Seismic Residential B
1 TRAVDOC Travel & Documentation B
Fee
Revised 12/06/10