14120104CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 1102 STEEPLECHASE LN
CONTRACTOR: JBS CONSTRUCTION
PERMIT NO: 14120104
OWNER'S NAME:
CUPERTINO, CA 95014
PHONE NO: (408)390-5577
®-- LICENSED CONTRACTOR'S DECLARATION
JOB DESCRIPTION: RESIDENTIAL COMMERCIAL
INSTALL TEMPORARY POWER
License Class`; 8� 1 Lic. # '750-521
Contractor f} 1,0 V Date 19 /
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
have and will maintain Worker's Compensation Insurance, as provided for by
APN Number: 35931038.00
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 O RMIT 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 FRO LED INSPECTIO
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
costs, and expenses which may accrue against said City in consequence of the
1 Date: �2 I `
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.
� Date /t'i
RE -ROOFS:
All roofs shall be inspected prior to any roofing material being installed. If a roof is
Signature
'
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. 1 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 225534.
Section 3700 of the Labor Code, for the performance of the work for which this
Owner or authorized agent: Dater
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
GENERAL PERMIT APPLICATION
D\)MEP
COMMUNITY DEVELOPMENT DEPARTMENT •BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 V
(408) 777-3228 • FAX (408) 777-3333 • building(a cupertino.org MISC
SING MECHANICAL LECTRICAL Q❑MISCELLANEOUS c/
a
PROJECT ADDRESS
l (
1
OWNER
PHO 2
E-MAIL,
STREET ADDRESS
cc /rS OV 6
CITY, STATE, ZIP- h T
FF
CONTACT NAME
STREET ADDRESS /
CITY, STATE, ZIP J !
F
❑ OWNER ❑ OWNER -BUILDER Q OWNER AGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME
LICENSE NUMBEI�
L
ENSETYPE n0S
BUS. LIC #
COMPANY NAME � ) _1 `-��
C"vGi
E-MAIL �
. CC
FAX
STREET ADDRESS2/S,3 L
Y, STATE, ZIP ��GM� �' �O
PHONE Z/ 3S
Q
ARCHITECT/ENGINEER NAME
LICENSE NUMBER
BUS. LIC #
COMPANY NAME
E-MAIL
FAX
STREET ADDRESS
CITY, STATE, ZIP
PHONE
USE OF ❑ SFD or DUPLEX ❑ MULTI -FAMILY
BUILDING: ElCOMMERCIAL
PROJECT IN WILDLAND ❑ YES
URBAN INTERFACE AREA ❑ NO
PROJECT IN ❑ YES
FLOOD ZONE ElNO
IS THE BLDG AN ❑ YES
EICHLER HOME? ElNO
DESCRIPTION OF WORK
TOTAL VALUATION: f oc)
By my signature below, I certify to each of the following: I am the property owner or authorized agent to4Ton the property o s bah . ave read this
application and the information I have provided is correct. I have read the Description of Work and verify it is accurate. I ag ply with all applicable local
ordinances and state laws relating to building cons tru ion. I authorize repres atives of Cupertino to enter the above -identified property for inspection purposes.
r
Signature of Applicant/Agent: Date:
�rIIPPLEMENTAL INFORMATION REQUIRED Y
OFFICE USE ONLY
MEPMiscApp_2011.doc revised 06/21/11
CITY OF CUPERTINO
FEE ESTIMATOR - BUILDING DIVISION
ADDRESS: 1102 Steeple Chase DATE: 12/19/2014 REVIEWED BY: Melissa
APN: 359 31 038 BP#: *VALUATION: $200
xPERMIT TYPE: Electrical Permit PLAN CHECK TYPE: Alteration / Addition / Repair
PRIMARY PENTAMATION 1REAP14
USE: SFD or Duplex PERMIT TYPE:
WORK IINSTALL TEMPORARY POWER
SCOPE
APPLIANCE / EQUIP TYPE
FEE ID
- _ _
QTY/FEE
QTY
UNITS
BP FEES
Temporary Power
1ERT<200
100
Amps
$48
PME Unit Fee:
$48.00
PME Permit Fee:
$48.00
—T7=
Consfrv".,tion 7'(M —F7L—
Administrative Fee: IADMIN
$45.00
Work Without Permit? ® Yes (j)No
$0.00
TOTALS:
Travel Documentation Fee: ITRAVDOC
$48.00
Strong Motion Fee: 1BSEISMICR
k k cl!;. Ylrrrr t_'hec k
TI-lt. -/7""a Fee.
fnt q . 1,, <—c
Plural> Plata Check
Ttramh. Tlermit Tee
other PlUrnh Ins;.
P1711 B, h7sp. Fee:
F;
Elec. Plan Check 0.0 hrs $0.00
Elec. Permit Fee: IEPERMIT
Other Elec. Insp. 0.0 hrs $48.00
Rrhnni
NOTE: This estimate does not mcluue fees aue to orner __-___,
tho Dont fnr addn'l info.
District, etc). inese fees are ouseu un iae �c.��k.u•
FEE ITEMS (Tee Resolution 11-053 Eff. 711113)
•• �••�•�•w• ..--�--
FEE
- _ _
QTY/FEE
____ ___
MISC ITEMS
gg
Pian
EEiPME Plan Check:
$0.00
PME Unit Fee:
$48.00
PME Permit Fee:
$48.00
—T7=
Consfrv".,tion 7'(M —F7L—
Administrative Fee: IADMIN
$45.00
Work Without Permit? ® Yes (j)No
$0.00
Ec/ 't rtc'c;U Plormirig Fees:
Travel Documentation Fee: ITRAVDOC
$48.00
Strong Motion Fee: 1BSEISMICR
$0.50
Select an Administrative Item
Bldg Stds Commission Fee: 1BCBSC
$1.00
$190.50
$0.00 _ ;, TONAL FEE:
$190.50
Revised: 10/01/2014