10070158 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADIJRESS: 6235 SHADYGROVE DR CONTRACTOR: PERMIT NO: 10070158
OWNER'S NAME: EDWARD A AND PAMELA J JAJKO L /; t"_ ` L4 I �cA DATE ISSUED:07/22/2010
.NER'S PHONE: 4084461306 PHONE NO:
LICENSED CONTRACTOR'S DECLARATION (— I—
BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class C l Lic.# 3
' ` ��-f MECH RESIDENTIAL COMMERCIAL
Contractor �;ejl ifm , CMo [L CIeC Date w f ul(D
I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION: ELECTRICAL PANEL UPGRADE TO 200 AMPS,SAME
(commencing with Section 7000)of Division 3 of the Business&Professions LOCATION
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.
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 Sq.Ft Floor Area: Valuation:$2800
permit is issued. 1<
APPLICANT CERTIFICATION APN Number:37540021.00 Occupancy Type:
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 PERMIT EXPIRES IF WORK IS NOT STARTED
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the WITHIN 180 DAYS OF PERMIT ISSUANCE OR
granting of this permit. Additionally,the applicant understands and will comply 180 DAYS FROM LAST CALLED INSPECTION.
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18. �----�
Issued by: -�_'�-- - Date:-?_ 7--1 -L o
Signature Date ^21 -10
Li O ER-BUILDER DECLARATION
RE-ROOFS:
I hereby affirm that I am exempt from the Contractor's License Law for one of All roofs shall be inspected prior to any roofing material being installed.If a roof is
the following two reasons: installed without first obtaining an inspection,I agree to remove all new materials for
1,as owner of the property,or my employees with wages as their sole compensation inspection.
will do the work,and the structure is not intended or offered for sale(Sec.7044,
Business&Professions Code) Signature of Applicant: Date:
I,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business&Professions Code). ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
I hereby affirm under penalty of perjury one of the following three
declarations: HAZARDOUS MATERIALS DISCLOSURE
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 I have read the hazardous materials requirements under Chapter 6.95 of the
performance of the work for which this permit is issued. California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain
I have and will maintain Worker's Compensation Insurance,as provided for by compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
Section 3700 of the Labor Code,for the performance of the work for which this Safety Code,Section 25532(a)should I store or handle hazardous material.
Additionally,should I use equipment or devices which emit hazardous air
permit is issued. contaminants as defined by the Bay Area Air Quality Management District I will
I certify that in the performance of the work for which this permit is issued,I shall maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
not employ any person in any manner so as to become subject to the Worker's Health&Safety Code,Sections 25505,25533,and 25534.
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 Owner or aythj�ized agent:
forthwith comply with such provisions or this permit shall be deemed revoked. r `'U`` Date: ? ?z� -io
APPLICANT CERTIFICATION CONSTRUCTION LENDING AGENCY
I certify that I have read this application and state that the above information is I hereby affirm that there is a construction lending agency for the performance of work's
correct.I agree to comply with all city and county ordinances and state laws relating for which this permit is issued(See.3097,Civ C.)
to building construction,and hereby authorize representatives of this city to enter Lender's Name
upon the above mentioned property for inspection purposes.(We)agree to save
-mify and keep harmless the City of Cupertino against liabilities,judgments, Lender's Address
,and expenses which may accrue against said City in consequence of the
granting of this permit.Additionally,the applicant understands and will comply ARCHITECT'S DECLARATION
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18. I understand my plans shall be used as public records.
Signature Date Licensed Professional
CITY OF CUPERTINO
FEE ESTIMATOR- BUILDING DIVISION
ADDRESS: 7DATE: REVIEWED BY:
APN: BP#: 'VALUATION: 1$2,800
PERMIT TYPE: Electrical Permit PLAN CHECK TYPE: Alteration/Addition / Repair
PRIMARY i(�l SFD or Duplex +1.. APPLICATION 1 R3SFDADD/REM
USE: =1 r�c1t� .�,�:, : TYPE:
09a
p0
3 �
APPLIANCE/EQUIP TYPE CAPACITY FEE ID QTY BP FEES
Temporary Power 1 EIRT<200 1 $42
TOTALS: $42.00
Elec.Plan Check0.0 hrs $0.00
Elec.Permit Fee: IEPERMIT
771 Other Elec.Insp. 0.0 1 hrs $42.00
NOTE. Thesefees are based on the preliminary in ormation available and are only an estimate. Contact the De t or addn 7 info.
FEE ITEMS (Fee Resolution 09-051 F_ ': 7:'/,,119) FEE QTY/FEE MISC ITEMS
PME Plan Check: $0.00
PME Unit Fee: $2.2.00
PME Permit Fee: $z 2.00
Travel Documentation Fee: ITIN VDOC $x.2.00
Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC 51.00
SUBTOTALS: $127.001 $0.00 TOTAL FEE: $127.00
Revised: 6/30/2010
CITY OF CUPERTINO
4 ITEMS OF 5 PERM-.'T RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: B--k: Lot:
APN . . . . . . . . : 3''540021 .00
DATE ISSUED. . . . . . . : 0'1/22/2010
RECEIPT #. . . . . . . . . : BS000010942
REFERENCE ID # . . . : 10070158
SITE ADDRESS . . . . . : 6235 SHADYGROVE DR
SUBDIVISION . . . . . .
CITY . . . . . . . . . . . . . . CUPERTINO
IMPACT AREA . . . . . .
OWNER . . . . . . . . . . . . : EDWARD A AND PAMELA J JAJKO
ADDRESS . . . . . . . . . . : 6235 SHADYGROVE DR
CITY/STATE/ZIP . . . : CUPERTINO CA, CA 95014
RECEIVED FROM . . . . : SERGE JULLIA
CONTRACTOR . . . . . . . : TBD - TO BE DETERMINED LIC # 00096
COMPANY . . . . . . . . . . : TBD - TO BE DETERMINED
ADDRESS . . . . . . . . . .
CITY/STATE/ZIP . . . : ,
TELEPHONE . . . . . . . .
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ----------- ---------- ---------- ----------
1BCBSC VALUATION 2, 800 . 00 1 . 00 0 . 00 1. 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 127 .00 0 .00 127. 00 0 . 00
CITY OF CUPERTINO
RECEIPT NUMBER: BS000010942
RECEIVED BY: PATG PAYOR: SERGE JULLIA
TODAY'S DATE: 07/22/10 REGISTER DATE: 07/22/10
TIME: 13 : 53
5
1BCBSC 10070158 $1 .00
1EPERMITFE 10070158 $42 .00
1ERT<200 10070158 $42 .00
1TRAVDOC 10070158 $42 .00
BUSINESS LICENSE TAX NEW-SERGE JULLIA CONST $114 .00
----------------
TOTAL DUE: $241. 00
CREDIT CARD: $241. 00 REF NUM: MC
TENDERED CHANGE
$241. 00 $. 00
CITY OF (: