11010143CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 21602 VILLA MARIA CT
CONTRACTOR: -fftD---Tf) BE PERMIT NO: 11010143
9E-TC41vttMED
OWNER'S NAME:
PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION
JOB DESCRIPTION: RESIDENTIAL U COMMERCIALff
License Class t 0 Li,. #
INSTALL 220 V 40 AMP CIRCUIT APPROX 30-35'FROM
100 AMP LOAD CENTER AT GARAGE TO OWNERS SPECS
Contractor r< �-J—r Date
LOCATION INSTALL 1240 VOLTSW CHARGING UNIT
I hereby affirm that I am licensed under the provisions of ihapter 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
Sq. Ft Floor Area:
Valuation: $600
performance of the work for which this permit is issued.
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
APN Number: 36638018,00
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: 1,6-7
granting of this permit. Additionally, the applicant understands and will comply
with all non -point source regulations per the Cupertino Municipal Code, Section
9.18.
RE -ROOFS:
Signature i/o)�V`1
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
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)
1, 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 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 25534.
Section 3700 of the Labor Code, for the performance of the work for which this
Owner or authorized : Date:#7 A/
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 this permit shall be deemed revoked.
work's for which this permit is issued (See. 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
CITY OF CUPERTINO
FEE ESTYU:.TOR — BUILDING DIVISION
ADDRESS: 21602 villa mania ct.
DATE: 01/27/2011
REVIEWED BY: bobs.
li¢ APN:
BP#:
VALUATION: $0 �=
*PERMIT TYPE: Electrical Permit
PLAN CHECK TYPE: Alteration / Addition / Repair
PRIMARY
USE: SFD or Duplex
PENTAMATION 1 REAP7
PERMIT TYPE:
WORK
install dockinq station at existin sfd ara a location.
SCOPE
APPLIANCE / EQUIP TYPE
FEE ID
QTY
UNITS
BP FEES
Apparatus
1BREMMISC
1
#
$126
TOTALS:
$126.00
i zc t. Plan C`hef—I
111,10d). Flag Che"'A"
Elec. Plan Check 0.0 hrs $0.00
i-'IarmL florjr,,O F<�e;
Elec. Permit Fee: IEPERAffT
0t1wr, c1k MSP.
01,,,-,r Phmnb i =r>.
Other Elec. Insp. 0.0 �rs$42.00
NOTE. These fees are based on the Preliminary information available and are only an estimate. Contact the Dept. for addn 7 info.
FEE ITEMS (Fee Resolution 49-051 Eff 7/11,70)
FEE
QTY/FEE
MISC ITEMS
Plan Check f, e :
S41pr)L PC h1,
PME Plan Check:
$0.00
Permit h:.e
.`styppl. Insp I*ee
PME Unit Fee:
$126.00
PME Permit Fee:
$42.00
("onso—I'l °tion' Ta
Work Without Permit? 0 Yes E) No
$0.00
Planning 11t,,e's:
Travel Documentation Fee: ITRAVDOC
$42.00
Strong Motion Fee:
$0.00
Select an Administrative Item
Bldg Stds Commission Fee:
$0.00
SUBTOTAL -.
$210.00
$0.00 TOTAL FEE:
1 $210.00
Revised: 01115/2011