14040192 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 11508 CHARSAN LN CONTRACTOR:B R ELECTRIC PERMIT NO: 14040192
OWNER'S NAME: XIAOYUN ZHU 54 ARENAS CT DATE ISSUED:04/29/2014
OWNER'S PHONE: 4088385691 SAN RAMON,CA 94583 PHONE NO:(925)922-7371
4a LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL ❑ COMMERCIAL ❑
q INSTALL(N)220 OUTLET(NEMA 14-50)IN GARAGE WITH
License Class C-zn Lic.# !d� j / DEDICATED CIRCUIT 50 AMP BREAKER
Contractor Date ` ' -6`
I hereby affirm that I am licensed u e the provisions of Chapter 9
(commencing with Section 7000)of ,ion 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
f performance of the work for which this permit is issued. Sq.Ft Floor Area: Valuation:$575
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:" 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 PE 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 ED 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 41
granting of this permit. Additionally,the applicant understands and will co Date:
with all non-point source re ulations per the Cupertino Municipal Code,Section
9 18.
J/ RE-ROOFS:
Signature Date � 711 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-BUILD 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)
1,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,Sectiop45 , 533,and 25534. /
Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agent: 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 LEND 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
V
GENERAL PERMIT APPLICATION ��
o M EP
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION O�
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255MMM I S C
(408) 777-3228•FAX(408)777-3333•buildino(alcuoertino.org \
C E1 p>`Ei't'C h1 O
❑PLUMBING ❑MECHANicAL ELECTRICAL ❑MISCELLANTEOUS
PROSECT ADDRESS C he I APN#
OWNER NAME , PHONE
STREET ADDRESS 0 0 V181,r 5CAVI Ln
CrM STATE,(ZIP.. �(Df I FAX
CONTACT NAME PHONE E-MAIL
STREET ADDRESS CITY,STATE,ZIP F24AX
❑ OWNER ❑ OWNER-BUBAER ❑ owNERAGENT CONTRACTOR ❑CONIRACTORAGENT ❑ ARCHITECT ❑ENGIN= ❑ DEVELOPER ❑TENANT
CONTRACTOR NAME t LICENSE NUMEER �j Q I LICENSE TYPE BUS.LIC 4
COMPANY NAME //yypCo ,,�/
E-MAII FAX
66:
STREET ADDRESS I CITY,STATE,ZIP PHONE 71
1'4 fill 5 r22 W2`
ARCH17ECT/ENGINEER NAME LICENSE NUMEER. BUS.LIC#
COMPANY NAME E-MAIL. FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF ❑SFD or DUPLEX ❑ MULTI-FAMILY PROJECT IN VILDLAND ❑ YES PROJECT IN ❑YES IS THE BLDG AN ❑YES
BUILDING. ❑COhMERCIAL URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑NO EICHLER HOME? ❑NO
DESCRIPTION OF WORK
TOTAL VALUATION: A 7-5!! RE
V
• - .w _'
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 Mth all applicable local
ordinances and state laws relating uild' traction. I authorize representatives of Cupertino to enter the above-identifiedpropertyfor inspection purposes.
Signature of Applicant/Agent: Date: q-j/- L t/
SUPPLEMENT NATION REQ U=D r
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MEPMisc,4pp_2011.doc revised 06/21/11
CITY OF CUPERTINO
FEE ESTIMATOR—BUILDING DIVISION
ADDRESS: 11508 CHARSAN LN DATE: 04/29/2014 REVIEWED BY: MELISSA
APN: 362 10 068 BP#: *VALUATION: $570
*PERMIT TYPE: Electrical Permit PLAN CHECK TYPE: Alteration/Addition / Repair
PRIMARY PENTAMATION
USE: SFD or Duplex PERMIT TYPE: 1 REAP A
WORK INSTALL N 220 OUTLET NEMA 14-50 IN GARAGE WITH DEDICATED CIRCUIT 50 AMP
SCOPE BREAKER
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Special Circuits 1BREMMISC 1 # $139
Recep/Switch/Outlets 1BREMRECEP 1 # $47
TOTALS: $186.00
b;a<car. 1'frn(-`heck Pfzoilb. Plan t'hecn Elec.Plan Check 0.0 hrs $0.00
v1i>ci=. Pc>,ntit Fee: f'htmh. Nm mil Fee: Elec.Permit Fee: IEPERMIT
C1rlwv.lfcc h. fn'}p' 011"er Phemb Insp. Other Elec.Insp. 0.0 hrs $47.00
V<!(h.. Inv), Fe, T1ionh hup. Fee: Insp. kee
NOTE: This estimate does not include fees due to other Departments(Le.Planning,Public Works,Fire,Sanitary Sewer District,School
District,etc). These ees are based on the prelinddua information available and are only an estimate. Contact the De t or addn'l info,
FEE ITEMS (Fee Resolution 11-053 Eff 7/1/13) FEE QTY/FEE MISC ITEMS
Man, Check l'i'e.
PME Plan Check: $0.00
PME Unit Fee: $186.00
PME Permit Fee: $47.00
iIon 1 aX.'
Administrative Fee: 1ADMIN $44.00
Work Without Permit? ® Yes ID No $0.00
2c1 E rrc<c9Planning,Imes:
Travel Documentation Fee: 1TRAVDOC $47.00
Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item
Blda Stds Commission Fee: 1BCBSC $1.00
r
tr $325.50 $0.00 TOTAL FEE: $325.50
Revised: 04/01/2014