14020015 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10121 SANTA CLARA AVE CONTRACTOR:MAINE ELECTRIC INC PERMIT NO: 14020015
OWNER'S NAME: LUMACTOD RICHARD 599 LEISURE ST DATE ISSUED:02/04/2014
OWNER'S PHONE: 4088230849 LIVERMORE,CA 94551 PHONE NO:(925)443-3377
LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION RESIDENTIAL COMMERCIALE]
License Class i (Lic.# ?j 0 1-5-0 REMOVE AND REPLACE MAIN PANEL 100 AMP
Contractor�t n e F 1.e_ �G 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:$5000
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:32624024 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 AST CALLED INSP C ION.
indemnify and keep harmless the City of Cupertino against liabilities,judgments, �j /
costs,and expenses which may accrue against said City in consequence of the Issued b Date 7
granting of this permit. Additionally,the applicant understands and will comply Y'
with all non-point sour a gulati s e Cupertino Municipal Code,Section
918.
RE-ROOFS:
Sig Date <i 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&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 Ml,,yArea Air Quality Management District I
performance of the work for which this permit is issued. will maintain compliance with the C W pter 9.12 a d
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sermon 55Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized 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
GENERAL PERMIT APPLICATION / MEP
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION Cj
10300 TORRE AVENUE•CUPERTINO,CA 35014-3255
(408) 777-3228•FAX(408)777-3333•building gncuoertino.orqMISC
O 1�
GUp�k`t'tNO '�
❑PLUMBING ❑MECHANICAL OhECTPJCAJ, ❑MISCELLANEOUS
PROJECT ADDRESS f? 12 t s9n �'1R� C,e I APN#
OWT.ERNAME lei c c;,;-- L(,(M R c 1-6- PHONE g 9 Z3- 159Cf 9 F NAII
STREET ADDRESS D/ J CITY,STATE,ZIPS' '� SIN I FAX
CONTACT NAME E-MkIINer HvZr- 3�1 - z3
STREET ADDRESS CITY,STATE,ZIP
FAX
❑ OWNER ❑ 01, .W R-B=EE ❑ O-ANlERAGENr ❑ CONTRACTOR JacONTRACTORAGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTORNAMS LICENSENUhIBER LICENSE ME BUS.LIC#
2 i Z 913OZ SD I e-10
COMEET PANY NAME !a;J 1 l a EMAIL FAX c
"
STRADDRESS r l CITY,STATE,ZIP PHONE A -�y`/3-33 77
Cern u re s� L� ve, r g ccs
ARCHTTECT&NGINEER NAME LICENSE NUMBER BUS.LIC:.
COMPANY NAI,S E-MAIL FAX
STREET ADDRESS CITY,STATE Z PHONE
USE OF FD or DUPLEX ❑ MUL71-FAMILY PROJECT IN WIIALAND ❑ YES PROJECT IN ❑YES IS THE BLDG AN ❑YES
BUIIDING: ❑COMMERCIAL , URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑NO EICHLER HOME? ❑ NO
DESCRIPTION OF WORK
TOTAL VALUATION:
��FrD Y ��
u.:M :
By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on the property owners behalf. I have read this
application and the information I have provided is.correct. I have read the Description ofWor and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating to building constriptiqjt I author- a epre tatwe of�ino erthe above-idntifiipd property for inspection purposes.
Signature of Applicant/Agent: ate:
SUPPLED TFORMATION REQUIRED
sl<co> �M
IN -Ei0-10
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MEPMisc-Ipp_2011.doc revised 06/21/11
CITY OF CUPERTINO
FEE ESTIMATOR— BUILDING DIVISION
W�PERMIT
DDRESS: 10121 santa clava ave DATE: 02/04/2014 REVIEWED BY: Mendez
PN: BP#: VALUATION: $5,000
PE: Building Permit PLAN CHECK TYPE: Alteration / Repair
PRIMARY SFD or Duplex PENTAMATION 1 REAP2
USE: p PERMIT TYPE:
WORK remove and replace main panel 100 am
SCOPE
1111w7>.P/u,-1 Che,�<, Elec.Plan Check 0.0 hrs $0.00
YfcrE;r',. P>r;�rit Fec. F'dttr i1. 1'e mir Elec.Permit Fee: IEPERMIT
0/her F'lumb Irsp- Other Elec.Insp. 0.0 hrs $47.00
Tl:�rztzz Tips z. Tee_ l iec.Imp
NOTE: This estimate does not include fees due to other Departments(La Planning,Public Works,Fire,Sanitary Sewer District,School
District,etc. . Theseees are based on the prelimina information available and are only an estimate. Contact the Dept for addh7 info.
FEE ITEMS (Fee Resolution 11-053 E . 7ff 11113) FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 F7TKI amps Electrical
Suppl.PC Fee: (D Reg. 0 OT 0.0 hrs $0.00 $47.00 IBELEC200 Services
PME Plan Check: $0.00
Permit Fee: $0.00
Suppl. Insp. Fee-E) Reg. () OT 0.0 1 hrs $0.00
PME Unit Fee: $0.00
PME Permit Fee: $47.00 T__=
Administrative Fee: 1ADMIN $44.00 0
Work Without Permit? ® Yes 0 No $0.00 G
Advanced Planning Fee: $0.00 Select a Non-Residential
Travel Documentation Fee: ITRAVDOC $47.00 Building or Structure A
Strong Motion Fee: 1BSEISMICR $0.50 Select an Administrative Item
Bldp,Stds Commission Fee: IBCBSC $1.00
$139.50 $47.00 . ! , TOT--,A FEE: $186.50
Revised: 01/15/2014