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13090090 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 19660 VICKSBURG DR CONTRACTOR:DOVE'S SERVICES INC PERMIT NO:13090090 OWNER'S NAME: FOLCK LEAH G TRUSTEE PO BOX 2061 DATE ISSUED:09/12/2013 OWNER'S PHONE: 6509497389 SAN LEANDRO,CA 94577 PHONE NO:(510)376-6543 ❑ LICENSED CONTRACTOR'S'DECLARATION JOB DESCRIPTION: RESIDENTIAL 11 COMMERCIAL License Class NQ ,�Lie.# 6?65og4 2 PANEL UPGRADE 125 AMP Contractor�LL�.LiGl�2.-4iY+-e- Date l-0-6 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:$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:36910015.00 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 stats laws relating WITHIN WO 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 DA OM 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 91P 12 granting of this permit. Additionally,the applicant understands and will comply Issued by: Date: with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. RE-ROOFS: Signature e 2 ' l Date C2-43All roofs shall be inspected prior or to an roofing being installed.stalled.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 25505,25533,and 25534. Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agent:(n� 1 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. 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 GENERAL PERMIT APPLICATION ff,qO M E P COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION w 10300 TORRE AVENUE CUPERTINO, CA 95014-3255 (408)777-3228•FAX(408)777-3333•building(a.cupertino.org t V misc CUPERTINO `� ❑PLUMBING ❑MECHANICAL VIELECTIZICAL E]MISCELLANEOUS PROJECT ADDRESS /q4/ o ]�/ „/, j)v APN# IOq 10015 D DI C OWNER NAME I Q lam, l,l IFOO Ick/` ( K� PHONE/�O'-I 1 / /�(�gq EMAIL `�J STREET ADDRESS Ltd CITY,STATED,ZIP FAX l��0 1�r�kshu. r 0 T561(1 CONTACT NAME PHONE E-MAIL STREET ADDRESS CITY,STATE,ZIP FAX ❑OWNER ❑ OWNER-BUILDER ❑.OWNER AGENT W CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT CONTRACTOR NAME �r _j �„_n LICENSE NUMBEDD_ LICEI�SEITYPE -BUS.LIC6509 # COMPANY NAME t E-MAIL I (J FAX SC.h2�t CeS C1mle55e�t d1 ce G�tcoo.cow , Co "351-/6 61 STREET ADDRESS CITY,STATE,ZIP PHONE 'P6 &,A io t Std,r-, Le G_r&rio CA u 7' ,61 D 3?6 65 y'3 ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC# COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE USE OF E]SFFD or DUPLEX ❑ MULTI-FAMILY PROJECT IN WHOLAND ❑ YES 7PROJECT IN ❑YES IS THE BLDG AN ❑YES BUILDING: ❑COMMERCIAL - URBAN INTERFACE AREA ❑ NO D ZONE ❑NO EICHLER HOME? ❑NO DESCRIPTION OF WORK service., TOTAL VALUATION: V —2 By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on the property owner's behalf. I have read this application and the information I have provided is 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 ']ding construction. thorize representatives of Cupertino to enter the above-identified property for inspection purposes. Signature of Applicant/Agent: Date: SUPPLEMENTAL INFORMATION REQUIRED Nil MEPMiscApp_2011.doc revised 06/21/11 CITY OF CUPERTINO FEE ESTIMATOR—BUILDING DIVISION ADDRESS 19660 vicksburg dr DATE: 09/12/2013 REVIEWED BY: Mendez APN: BP#: 'VALUATION: 1$1,800 *PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration/ Repair PRIMARY SFD or Duplex PENTAMATION 1 REAP2 USE: PERMIT TYPE: WORK ane! upgrade 125 am SCOPE v _ r Xkch. flan Check Plutub. Plan Check Elec.Plan Check 0.0 hrs $0.00 l tech.Perrnit Fee: Plumb. Permit lee: Elec.Permit Fee: IEPERMIT Otlrer Afech.Insp, Other Plumb Insp. Other Elec.Insp. 0.0 hrs $47.00 11.e:ch_Insp. Fe,. Plumb. Insp.Fee: Elec.Insp.Fere: NOTE.This estimate does not include fees due to other Departments(i.e.Planning,Public Works,Fire,Sanitary Sewer District,School District,eta). Theseees are based on the preffinWdna information available and are only an estimate. Contact the De t or addn7 info. FEE ITEMS(Fee Resolution 11-053 E . 7�) FEE QTY/FEE MISC ITEMS Plan Check Fee: $0.00 = amps Electrical Suppl.PC Fee: (2) Reg. ® OT0.0 hrs $0.00 $47.00 IBELEC200 Services PME Plan Check: $0.00 Permit Fee: $0.00 Suppl. Insp.Feer Reg. ®OT 0.0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $47.00 Construction :T ar: Administrative Fee: 1ADMIN $44.00 Work Without Permit? ®Yes G) No $0.00 0 Advanced Planning Fee $0.00 Select a Non-Residential G Travel Documentation Fee: 1TPA VDOC $47.00 1 Building or Structure i Strong Motion Fee: 1BSEISMICR $0.50 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $1.00 � n $139.50 $47.00 a= p $186.50 Revised: 08/01/2013