10020058 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 7520 KIRWIN LN CONTRACTOR:COBALT POWER PERMIT NO: 10020058
SYSTEMS,INC
_'VNER'S NAME: POLLOCK JEFFREY J AND BRENDA J 885 MAUDE AVE DATE ISSUED:02/10/2010
%jWNER'S PHONE: 4082523594 MOUNTAIN VIEW,CA 94043 PHONE NO:(650)938-9574
❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL COMMERCIAL
License Class - (� Lice.# 0 ol PANEL UPGRADE TO 200 AMP
Contractor C.e3LC(� � i,, 5 SDate d v
I hereby affirm that I am licensed under the provisions of C apter 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:$1800
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:35923003.00 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, 1 J
costs,and expenses which may accrue against said City in consequence of the � Date:
grantingpermit.
r5 [ (J
rantin of this P ermit. Additionally,the applicant understands and will comply Issued by: �J J
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18.
RE-ROOFS:
c;-nature s a � Date Z CO �O 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 o.'
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 compensatior,
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. 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(x)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 agent`~ S 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 mu:,t 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 relatir g
to building construction,and hereby authorize representatives of this city to enter
the above mentioned property for inspection purposes.(We)agree to save ARCHITECT'S DECLARATION
mify and keep harmless the City of Cupertino against liabilities,judgments,
CURS,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 "zU_Q �--) Date D
CITY OF CUPERTINO
5 ITEMS OF 5 PERMIT RECEIPT OPERATOR: SylviaM
COPY # : 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN 35923003 . 00
DATE ISSUED. . . . . . . : 02/10/2010
RECEIPT #. . . . . . . . . BS000009729
REFERENCE ID # 10020058
SITE ADDRESS 7520 KIRWIN LN
SUBDIVISION . . . . . . .
CITY CUFERTINO
IMPACT AREA . . . . . .
OWNER POLLOCK JEFFREY J AND BRENDA J
ADDRESS 750 KIRWIN LN
CITY/STATE/ZIP . . . : CUPERTINO CA, CA 95014-4337
RECEIVED FROM COBALT POWER SYS
CONTRACTOR MARK BYINGTON LIC # 26071
COMPANY COBALT POWER SYSTEMS, INC
ADDRESS 885 MAUDE AVE
CITY/STATE/ZIP MOI7NTAIN VIEW, CA 94043
TELEPHONE (650) 938-9574
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- -------------
---------- - --------- ---------- -
1BCBSC VALUATION 1, 800 . 00 1. 00 0 .00 1 . 00 0. 00
1BSEISMICR VALUATION 1, 800 . 00 0 . 50 0 .00 0 . 50 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 - ----
---------- ---------- ----------
TOTAL PERMIT 127.50 0 . 00 127 . 50 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
-----------------
--------------- --------------------
CREDIT CARD 127.50 visa
---------------
TOTAL RECEIPT 127 . 50
{aZ CICITY OF CUPERTINO
CUPE�TiNO GENERAL BUILDING
PERMIT APPIACATION FORM
APN# Date:
�� 23 aU3-cam 2 �o Zai 0
Building Address: 7��o
I- r Lo t'^
Mailing Address (if different from building address)
Are Hazardous Materials being used as part of this project? Yes U No
HOA: Exterior work only) Yes ❑ No ❑ If yes, provide letter from HOA
Owner's Name: ,/ Phone#: ,i4c Z�-Z _ '�S^ry C(
d
La C,�'c `®c`
Contractor: �,-
Phone:
6,5 D1.�k�-
S Fax: p
Contractor License#: (o1
Cupertino Business License#: .12 fo 0
Contact: Phone: 4 S-0-71'Y-S'(Z T
1-pNo �- s Fax: 6 739' 73
Residential Commercial
Job Description: F(r_
Building Permit Info:
Bld ❑ Elect Plumb ❑ Mech ❑
Type of Construction (Usage Class): Occupancy Type:
1-A 1-B II/III/V-A 0 II/III B, IV-HT,`'-B 54 �-&
Valuation: Square Footage:
Project Size: Ex ressEg- Standard ❑ Largs; ❑ Major ❑
Green Building: Please complete relevant portion of the Green Building/LEED Checklist& attach it
to the application or if applicable, include in plan set& the sheet index.
Points Achieved:
For help, contact Build it Green at www.builditg reen.or
Revised 07/14/09
CITY OF C'UPERTINO
CITY of GENERAL BUILDING APPLICATION
CUPEI�TINO
FEE SCHEDULE
Quantity/Sf Fee ID Fee Description Fee Permit Type
Group 1GENRES or
1GENCOM
1STUCOAP Stucco Applications (up to 400 sf) B
additional stucco application
1 WINREP Replacem,;nt windows/sliding glass B
door (ea f windows)
1 WINMEWSTR New Winslow-structural shear B
wall/masonry(includes plan ck fee)
1 EPERMITFEE Electrical Permit Fee E
1 MPERMITFEE Mechanical Permit Fee M
1 PPERMITFEE Plumbing Permit Fee P
IELCPLNCK Stand Alo:ie Electric Pln Ck (hourly) E
1MECPLNCK Stand Alo:ie Mechanical Pln Ck(hrly) M
1PLMBLNCK Stand Alo:le Plumbing Pln Ck(hrly) P
1 STPLNCK-(3 Hr Min Standard Flan Check(when no E/M/P) B
when not over counter) hourly-staid alone
1 1BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT
( TYPES
1BSEISMICR Seismic R-'sidential B
1 BSEISMICO Seismic C)mmercial B
I 1 TRAVDOC Travel &Documentation B
1BUSLIC Business License B
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