14010108 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 19991 MERRITT DR, CONTRACTOR:ADVANCED PLUMBING PERMIT NO: 14010108
&ELECTRIC
OWNER'S NAME:
CUPERTINO,CA 95014 PHONE NO:(408)777-0651
❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: 'RESIDENTIAL 11 COMMERCIAL
License Class ��1 rr��-1 Lic.# -7 a,,,
UPGRADE 100 AMP
Contractor 8Yl V� C.e n
I hereby affirm that I am licensed r der the li'ovisi s 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:$1600
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:31630071.00 Occupancy Type:
permit is issued.
APPLICANT CERTIFICATION
I certify that I have read this application and state,thatthe 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 ERMIT 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 S FROM ALLED 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 Issued b Date:
granting of this permit. Additionally,the applicantunderstands and will comply 3'
with all non-point source regulations per the Cupertino Municipal Code,Section
918.
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&Profe'ssions 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,Secti
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 must I hereby affirm tha*here 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 C MEP
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION O V
10300 TORRE AVENUE•CUPERTINO,CA 95014-3255 \Q,
(408) 777-3228•FAX(408)777-3333•building CcDcupertino.org b y MISC
❑PLUMBING ❑MECHANICAL ELECTRICAL []MISCELLANEOUSMISC/E�LLLAA)NEOUS
PROJECT ADDRESS j g Q q I fie. j-- APN# 30,59
0 2 O /\-7
OWNER NAME 1 PHONE4 02 73 2 a v E-MAIL
STREETADDRESS p Q r /(fin 1 (,L Cf y CITY, STATE,ZIP. �i (' I FAX
CONTACT NAME CriL� t 7 aq R � E-MAILPHONES
STREET ADDRESS i C� fAVQC. CITY.STATE,ZIP a F o6
)
OWNER ❑ OWNER-BUILDER (/❑(ONMERAGENT CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT (/
CONTRACTOR NAME I� `�( „ Q LICENSENUNMER!�7 LICENSE TYPE BUS.LIC#
COMPANY NAME E-MAIL FAX
STREET ADDRESS F nc I CITY,STATE,ZIP e V j/r P4 0 C �/Z` PHONE
ARCHTTECT/ENGWEERNAME LICENSE NUMBER - BUS.LIC#
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF ❑SFD or DUPLEX MULTI-FAMILY PROJECT INWIIALAND ❑ YES PROJECT IN ❑YES IS THE BLDG AN ❑YES
BUILDING: ❑COMMERCIAL URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑NO EICHLER HOME? ❑ NO
DESCRIPTION OF WORK �/�, ^ ' r to /OVA
Pon 01
TOTAL VALUATION: 17— '000 �'RECEI9ED BY -
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 building construction. I authorize representatives of Cupertino to enter the abov�id ntified property for inspection purposes.
Signature of Applicant/Agent: _ SGt Date:
SUPPLEMENTAL DUQ97ATION REQUIRED oFcE-Js>s'oii�� -----
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� � 'ST.AIQDARD
MEPMisc,4pp_2011.doc revised 06/21/11
CITY OF CUPERTINO
FEE ESTIMATOR-BUILDING DIVISION
ADDRESS:19991 remitt dr DATE: 01/16/270147REVIEWED BY: Mendez
APN: BP#: *VALUATION: $1,600
*PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration/ Repair
PRIMARYPENTAMATION 1 REAP2
USE: SFD or Duplex PERMIT TYPE: i
WORK ane/ upgrade!100 am'
SCOPE
Wech.Plan Check PhunL Plan Check Elec.Plan Check 0.0 hrs $0.00
Llech. Perron Fee: Plumb.Permit Fee: Elec.Permit Fee: IEPER1l1IT
£�tlrcr :llech.Insp. Other-Plumb Insp. Other Elec.Insp. 0.0 hrs $47.00
Aaech.Insp.Fere: Plumb. hrep.Fee: Elec.Insp.Tee:
NOTE.This estimate does not include fees due to other Departments(Le.Planning,Public Works,Fire,Sanitary Sewer District,School
District,etc.). These fees are based on theprelimina information available and are only an estimate Contact the Dept for addn'1 info.
FEE ITEMS (Fee Resolution 11-053 E : 7111132 FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 100 amps Electrical
Suppl.PC Fee: 19 Reg. O OT 0.0 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 Tax:
Administrative Fee: 1ADMN $44.00
Work Without Permit? O Yes (E) No $0.00
Advanced Planning Fee: $0.00 Select a Non-Residential
Travel Documentation Fee: I TRAVDOC $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
Revised: 01/15/2014