13090052 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10410 N BLANEY AVE CONTRACTOR: r•O K&—' N ERMIT NO:13090052
OWNER'S NAME: ROHrFASHVA GUARAUA DATE ISSUED:09/09/2013
OWNER'S PHONE: 4084828484 PHONE NO:
L LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL COMMERCIAL
License Class Li..# 204k1a,011 UPGRADE(E) 100 AMP PANEL TO(N)200 AMP PANEL,
p�I /' SAME LOCATION
Contractor �09 1�1904LS t L' Date hQ
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:$2800
4/_ I have and will maintain Worker's Compensation Insurance,as provided for by
dip Section 3700 of the Labor Code,for the performance of the work for which this APN Number:31630092.00 Occupancy Type:
permit is issued.
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is PERMIT EXPIRE IS NOT STARTED
correct.I agree to comply with all city and county ordinances and state laws relating WIT AY RMIT 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 1 ST CALLED INSPEC ION.
indemnify and keep harmless the City of Cupertino against liabilities,judgments, G
costs,and expenses which may accrue against said City in consequence of the 5 / 13
granting of this permit. Additionally,the applicant understands and will co Issued by: -)Rate: _
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18.
.- ,y RE-ROOFS:
Signature Date—4 L1113 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
I hereby affirm that I am exempt from the Contractor's License Law for one of Signature of Applicant: Date:
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&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, ,and 25534.
Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agent: Date:—e?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
10300 TORRE•AVENUE•CUPERTINO, CA 95014-3255
GUPERTINO (408)777-3228•FAX(408)777-3333•buildincl(a.cupertino.ord f misc
❑PLUMBING EIMECHANICAL ELECTRICAL ❑MISCELLANEOUS
PROJECT ADDRESS j o _ 1//LV� ,� n�j ` APN# -3I�
OWNER NAMJQj��jpCS !"
V PHONE W
STREET ADDRES V t F1 / r I CITY, STATE,ZI �) y �r-j\1� FAX
CONTACT NAM PHONE r/nE-MAIILJ� C+� ( :oz
STREET ADDRESS J� , I,� !_ OK CITY, TATE,Z ,}J�U4 C^'Ll FAX
❑OWNER ❑ OWNER-BUIDER ❑ OWNER AGENT ONTRACTOR ❑CONTRACTOR AGENT ❑�\ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT
CONTRACTOR NA ^{. (A k LICENSE NUMBER 1 LIC�SE t:JTYPE BUS.LIC#
COMPANY NAM t � ` / E-MAIL /a�Q M}^ p FAX �v
STREET AD S I Ki,N (_ [`. A O�J CITY,STA IP PH (o(93
ARCHITECT/ENGINEER NAME M - LICENSE NUMBER `V BUS.LIC#
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF SFD or DUPLEX ❑ -MULTI-FAMILY PROJECT IN WIDLAND ❑ YES PROJECT IN ❑YES IS THE BLDG AN ❑YES
BUILDING: COMMERCIAL URBAN INTERFACE AREA NO FLOOD ZONE NO EICHLER HOME? O
DESCRIPTION OF WORK
TOTAL VALUATION: T/
By my signature below,I certify to each of the following: I am the property owner or authorize nt t ct o roperty o e' ehalf. I have read this
application and the information I have provided is orrect. I have read the Description of Work and Is accurate. I a o comply with all applicable local
ordinances and state laws relating to ' in ction. I authorize representatives of Cupertin o enter the above-'de Tied operty for inspection purposes.
Signature of Applicant/Agent: Date:
SUPPLItMEtt INFORMATION REQUIRED
r�
MEPMiscApp_2011.doc revised 06/21/11
CITY OF CUPERTINO
FEE ESTIMATOR—BUILDING DIVISION
ADDRESS: 10410 N BLANEY AVE DATE: 09/09/2013 REVIEWED BY: MELISSA
APN: 316 30 092 BP#: "VALUATION: 1$2,800
*PERMIT TYPE: Electrical Permit PLAN CHECK TYPE: Alteration/Addition/ Repair
PRIMARY SFD or Duplex PENTAMATION 1 REAP2
USE: PERMIT TYPE:
WORK UPGRADE E 100 AMP PANEL TON 200 AMP PANEL SAME LOCATION
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Services 1ERT<200 100 Amps $47
TOTALS: $47.00
wrrr,
:L1<<c:Fr. flan C'heckPhinib. Plan('heck Elec.Plan Check 0.0 hrs $0.00
Fm—,,/, Permit Fee: Plumb. Permit Fee: Elec.Permit Fee: IEPERMIT
Ckher Alech.Insp. Oiler Plumb Insp. Other Elec.Insp. 0.0 hrs $47.00 D I
Alech. fmp.Fee: Pluurb. Insp.Fee: Elee.Insp.Fee:
NOTE:This estimate does not include fees due to other Departments(La Planning,Public Works,Fire,Sanitary Sewer District,School
District,etc). These
-fees are based on the relimina
information available and are only an estimate- Contact the De t or addh7 info.
FEE ITEMS (Fee Resolution 11-053 E . 7111121 FEE QTY/FEE MISC ITEMS
Plan Check Fee:
.suppl. Pc::Pee
PME Plan Check: $0.00
Permit Fee:
Suppl. 1ns7p Fee
PME Unit Fee: $47.00
PME Permit Fee: $47.00
C:onsowciion Ttx.
Administrative Fee: IADMIN $44.00
Work Without Permit? ®Yes Q No $0.00
,I dvunced Planning Fees:
Travel Documentation Fee: ITRA VDOC $47.00 A
Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $1.00
V a tk3eiSc.
$186.50 $0.00 Y2�` 1 $186.50
Revised: 07/01/2013