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14010083 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 19681 VICKSBURG DR CONTRACTOR:EVERSPRING PERMIT NO:14010083 CONSTRUCTION INC OWNER'S NAME: SAN JOSE,CA 95129 PHONE NO:(408)446-8398 ❑ LICENSED CONTRACTOR'S.DECLARATION JOB DESCRIPTION:RESIDENTIAL ❑ COMMERCIAL r�/ INSTALL TEMP POWER License Class f3l Lie,# Contractori/ �d""' TevC�'gate ( fS 1 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:$200 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:36908018.00 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, costs,and expenses which may accrue against said City in consequence of the 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 918. _ -_ RE-ROOFS: Sign re Date 1 f f All roofs shall be inspecte 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,Sectio "s 2550,and 25534. Section 3700 of the Labor Code,for the performance of the work1.1 for which this Owner or 1 (S f 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 918. Signature Date GENERAL PERMIT APPLICATION MEP COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO,CA 95014-3255 Y (408) 777-3228•FAX(408)777-3333•buildingacupertino.org MISCY ❑PLUMBING OMECHANICAL ❑ELECTRICAL ❑MISCELLANEOUS PROJECT ADDRESS q 62� APN 9 369 og - n g OWNER NAME PHONE' Up Ems tit©, .R q�� I FAX CONTACT NAME I C, ,1 pl PHONE /�S / o z^�I 2 E'MAII STREET ADDRESS CITY,STATE Z - b� � FAX ((-31 S .1 Q-e Apt-6- E3 L��,y( rF>S� s (2 1 ❑ OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT ILTCONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR�iNANIE l LICENSE , o- LICENSE TYPE BUS.LIC# COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP P140I1TE ARCHI TECT/ENGINEER NAME LICENSE NUMBER BUS.LIC# COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE USE OF ❑SFD or DUPLEX ❑ MULTI-FAMILY PROJECT IN WILDLAND ❑ YES PROJECT IN ❑YES71ICJiLER THE BLDG AN EI YES BUII�ING: ❑COMMERCIAL URBAN INTERFACE AREA ❑ NO FLOOD ZONE E3NO HOME? ❑NO DESCRIPTION OF WORK TOTAL VALUATION: ZoG 10111" 4 _. By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on the pro o s behipt 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 com y with all applicable local ordinances and state laws relating to building co atives of Cupertino to enter the above-i0entified property for inspection purposes. Signature of ApplicantlAgent: Date: I I 13 xWHO,-- SUPPLEMENTAL INFORMATION REQUIRED ��; -oFII. . , �,?�OY,�F.R�-THI<rCOUNTER e ..as . EXERESS� :: �„ ga ''w x® I;ARE - Lzp j R k„ MEPMiscApp_2011.doc revised 06/21/11 CITY OF CUPERTINO FEE ESTIMATOR—BUILDING DIVISION ADDRESS::19681 VICKSBURG DR DATE: 01/15/2014 REVIEWED BY: MENDEZ APN: BP#: `VALUATION: $200 *PERMIT TYPE: Building.Permit PLAN CHECK TYPE: Alteration/Repair PRIMARY PENTAMATION USE: SFD or Duplex PERMIT TYPE: 1 REAP14 A WORK INSTALL TEMP POWER SCOPE 1 V1ec.h..Plan('heck Pttrrnb.Plzen Check Elec.Plan Check0.0 hrs $0:00 F1e1:11. Penn it Fee: Plumb.Permit Fee:: Elec.Permit Fee: 1EPERMIT Other Ale.ch.Insp.. (hirer Plumb Insh. Other Elea Insp. 0.0 hrs $47.00 Dlkch.Irzsh:I''c?e: F/utnb. Insp.Fee: Elec.Insp,Fere. NOTE.This estimate doesnot include fees due to other Departments(Le.Planning,Public Works,Fire,Sanitary Sewer District,School District,etc.). These fees are based on the prelindna information available and are only an estimate- Contact the De t or addn I info, FEE ITEMS (Fee Resolution 11-053 E . 7/1113) FEE QTY/FEE MISC ITEMS Plan Check Fee: $0.00 1 amps Electrical Suppl.PC Fee: (E) Reg. Q .OT 0:0 I hrs $0.00 $47.00 IERT<200 Temporary Power PME Plan Check: $0.00 Permit Fee: $0.00 Suppl. Insp.Fee 19 Reg. OT 0,0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $47.00 Construction Tax: Administrative Fee:. 1ADMIN $44.00 Work Without Permit? ®Yes (E) No $0.00 1 1 0 Advanced Planning Fee. $0.00 Select a Non-Residential 0 Travel Documentation Fee: 1TRAVDOC $47.00 Building or Structure Strong Motion.Fee: IBSEISMICR $0.50 Select an Administrative Item Bldg Stds Commission Fee: 1BCBSC $1.00 ' $139.50 $47.00 d n. , $186.50 Revised: 01/01/2014