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15010070, CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 20626 SCOFIELD DR CONTRACTOR: HUMMEL CUSTOM PERMIT NO: 15010070 CONSTRUCTION OWNER'S NAME: SAN JOSE, CA 95128 PHONE NO: (408) 483-0323 1 LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL ❑ COMMERCIAL ❑ INSTALL TEMPORARY POWER License Class Lic. # 2 3 3 to 6 Contractor jn&A(F 56- Date ) J3 '/J 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 APN Number: 35910009 00 Occupancy Type: Section 3700 of the Labor Code, for the performance of the work for which this 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 L LLED 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 ate: 3 S granting of this permit. Additionally, the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code, Section 9 18. Signature ��Dat. ' /J RE-ROOFS: 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 1, 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 (See.7044, Business & Professions Code) I, as owner of the property, am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE construct the project (See.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: 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 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 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 CUPERTINO 0 GENERAL PERMIT APPLICATION � COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION MEP \ v 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 O misc (408) 777-3228 • FAX (408) 777-3333 • buildingp_cupertino.ora /„ ,TATI� 1 II -TTA -AT 1\ /L'i 1111l TIAT AATCIL'iT ATTVI1T TC PROJECT ADDRESS APN # 1 357- 10 "00 7-� 24- s6oA.t4 E-MAIL STREET ADDRESS C FAX CS v CEO,ZIP ' !�6 CONTACT NAME PHONE E-MAIL STREET ADDRESS CITY, STATE; ZIP FAX 3 yy L s T G1oq ❑ OWNER ❑ OWNER -BUILDER ❑ OWNER AGENT CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME LICENSE NUMBER 7LICINS TYPE BUS. LIC # L6 rtrt �� GY COMPANY NAME E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP 6 PHONE 1 G .5ts e--,,4 9 /a Vag- 0 2 ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS. LIC # COMPANY NAME E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE USE OF llXrSFD or DUPLEX ❑ MULTI -FAMILY PROJECT IN WII,DLAND ❑ YES PROJECT IN ❑YES IS THE BLDG AN El YES BUILDING: El COMMERCIAL URBAN INTERFACE AREA NO FLOOD ZONE ANO EICHLER HOME? ji�$ NO DESCRIPTION OF WORK H , �� 4� G MEPMiscApp_2011.doc revised 06/21/11 CITY OF CUPERTINO FEE ESTIMATOR - BUILDING DIVISION APPLIANCE / EQUIP TYPE FEE ID QTY UNITS BP FEES Temporary Power 1ERT<200 100 Amps $48 TOTALS: $48.00 ADDRESS: 20626 SCOFIELD DR DATE: 01/13/2015 REVIEWED BY: MELISSA Phinih. ]Tart Checi, APN: 359 10 009 BP#: "VALUATION: $200 xPERMIT TYPE: Electrical Permit PLAN CHECK TYPE: Alteration / Addition / Repair PRIMARY SFD or Duplex p Other Elec. Insp. 0.0 hrs $48.00 PENTAMATION 1 REAP14 USE: 1=lec. hzsp, PERMIT TYPE: WORK INSTALL TEMPORARY' POWER SCOPE PME Unit Fee: APPLIANCE / EQUIP TYPE FEE ID QTY UNITS BP FEES Temporary Power 1ERT<200 100 Amps $48 TOTALS: $48.00 NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School District etc These ees are based on the Drelimina information available and are only an estimate. Contact the Dept for addn7 info. FEE ITEMS (Fee Resolution 11-053 Eff.' 7111131 FEE QTY/FEE MISC ITEMS Phinih. ]Tart Checi, Elec. PlanCheck 0.0 hrs $0.00 3A -ch, Pf,rouit fe;e: l'l imb. Pertn"I7 Fee. Elec. Permit Fee: IEPERMIT ether Plvmh Iris, Other Elec. Insp. 0.0 hrs $48.00 ilcz ', 3v"- I'hi 0n lies. Fee: 1=lec. hzsp, NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School District etc These ees are based on the Drelimina information available and are only an estimate. Contact the Dept for addn7 info. FEE ITEMS (Fee Resolution 11-053 Eff.' 7111131 FEE QTY/FEE MISC ITEMS Plan Checlt F,' >. PME Plan Check: $0.00 fe,;rait l:� e: PME Unit Fee: $48.00 PME Permit Fee: $48.00 CClitstri.iction l a : Administrative Fee: ]ADMIN $45.00 Work Without Permit? ® Yes 0 No $0.00 Travel Documentation Fee: ITRAVDOC $48.00 Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $1.00 .�Q ®� r: $190.50 $0.00 TOTAL FEE: $190.50 Revised: 01/06/2015