13080022 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10372 SCENIC CIR CONTRACTOR:PL ELECTRIC PERMIT NO:13080022
OWNER'S NAME:
SAN JOSE,CA 95119 PHONE NO:(408)427-7276
LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL 11 COMMERCIAL
License Class -- T Q Lic.# 5 I UPGRADE(E)125 AMP PANEL TO(N)200 AMP PANEL,
J � 4 l SAME LOCATION
Contractor ` � A-tc Date � ' � '/
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:$2500
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:35707025.00 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 FROMJASTXALLED 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
granting of this pe it. Additionally,the applicant understands and will comply Date:
with all non-poin so rce regulations,per the Cupertino Municipal Code,Section
9.18.
}�+ ) RE-ROOFS:
Signature Date 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)
I,as owner of the property,am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE
construct the project(Sec.7044,Business&i 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 thupertino Municipal Code,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sec' n q_25505,25533,and 25534. (�
Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agent: Date: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(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
V�
GENERAL PERMIT APPLICATION o MEP
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION O Q
10300 TORRE AVENUE•CUPERTINO,CA 95014-3255 �D MISC
CUPERTINO (408)777-3228=FAX(408)777-3333•building(c)-cupertino.org
❑PLUMBING ❑MECHANICAL ELECTRICAL �7 ❑MISCELLANEOUS
PROJECT ADDRESS /() 3 '� ¢ ,+, APN#
OWNER NAME
` �� PLO
CONTACT NAME PHONE E-MAIL.
STREET ADDRESS CITY,STATE,ZIP FAX
❑OWNER ❑ OWNER--BBBBUILDER ❑ OWNER AGENT 11CONTRACTOR ElCONTRACTOR AGENT 11 ARCHITECT 11ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME �^" G�G�L LICENSE MBER LICENSE TYPE BUS.LIC#
COMPANY NAME L - 7 E-MAIL FAX
STREET ADDRESS,,/
ARCHITECT/ENGINEERNAME LICENSE NUMBER V / BUS.LIC#
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF SFD or DUPLEX ❑ .MULTI-FAMILY PROJECT INWILDLAND ❑ YES PROJECT IN ❑YES IS THE BLDG AN ❑YES
BUILDING: ❑COMMERCIAL URBAN INTERFACE AREA NO FLOOD ZONE 91110 EICHLER HOME? NO
DESCRIPTION OF WORK Al �� ✓ /a n
000g
TOTAL VALUATION: -S-0 V CEIVED'BY:'.;
By my signature below,I certify to each of the following: I am the property owner or authorized agent to act e property owner's behalf. I have read this
application and the information I have provi correct. I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating to b ' onstrue'on, iu#iorize rQsentatives of Cupertino to enter the above-identifie operttyf pection purposes.
Signature of Applicant/Agent: Date: Q]� ' �✓ jins
S LEMENTAL INFORMATION REQUIRED OFFICE USE ONLY
W OVER-THE-COUNTER
❑ EXPRESS
El V
STANDARD
U
LARGE
w
MAJOR
MEPMiscApp_2011.doc revised 06/21/11
CITY OF CUPERTINO
FEE ESTIMATOR-BUILDING DIVISION
ADDRESS: 10372 SCENIC CIR DATE: 08/05/2013 REVIEWED BY: melissa
APN: 357 07025 BP#: *VALUATION: 1$2,500
*PERMIT TYPE: Electrical Permit PLAN CHECK TYPE: Alteration/Addition/ Repair
PRIMARY SFD or Duplex PENTAMATION 1 REAP
USE: PERMIT TYPE:
WORK UPGRADE E 125 AMP PANEL TON 200 AMP PANEL SAME LOCATION
SCOPE
APPLIANCE/EQUIP TYPE FEE ED QTY UNITS BP FEES
Services 1 ERT<200 200 Amps $47
TOTALS: $47.00
.kfec:h. Plan Check PhanL Alun Check Elec.Plan Check 0.0 hrs $0.00
iblech.Permit Fee: Plumb.Permit Fee: Elec.Permit Fee: IEPERMIT
Ozher;Vlech. In, Other Plumb Insp. Other Elea Insp. 0.0 hrs $47.00
1fih. Insp.lee: Plurnb. hap.Fee: flee.Insp.Fee:
NOTE:This estimate does not include fees due to other Departments(Le.Planning,Public Works,Fire,Sanitary Sewer District,School
District,etc.). These ees are based on the preffinina information available and are only an estimate. Contact the De t or addn'l info,
FEE ITEMS (Fee Resolution 11-053 E . 711112) FEE QTY/FEE MISC ITEMS
Plan Check I4ee:
SuFhl. PCT'ee
PME Plan Check: $0.00
Peri'nit.Fee:
Appl. Insp Fee
PME Unit Fee: $47.00
PME Permit Fee: $47.00
Construction.Tax:
Administrative Fee: 1ADMIN $44.00
Work Without Permit? 0 Yes (j) No $0.00
,Advanced Planning Fees:
Travel Documentation Fee: 1TRAVDOC $47.00
Strong Motion Fee: 1BSEISMICR $0.50 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $1.00
:
$186.50 $186.50
�` Revised: 07/01/2013