15040062CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 7620 K1RWIN LN
OWNER'S NAME: MORRIS HERBERT G AND JANIE
OWNER'S PHONE: 4082575328
❑ LICENSED CONTRACTOR'S DECLARATION
License Class Lic. #
Contractor I to /( j
I hereby affirm that I am licensed under the provisions of Ch liter
(commencing with Section 7000) of Division 3 of the Business & Professions
Code and that my license is in full force and effect.
CONTRACTOR: ARIANA
CONSTRUCTION INC
PO BOX 612
FREMONT, CA 94537
PERMIT NO: 15040062
DATE ISSUED: 04/08/2015
PHONE NO: (510) 586-9494
JOB DESCRIPTION: RESIDENTIAL COMMERCIAL
125 AMP PANEL UPGRADE
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.
•1 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
permit is issued. ItPLICANT
CERTIFICATION
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
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
costs, and expenses which may accrue against said City in consequence of the
granting of this permit. Addition the applicant understands and will comply
with all non -point s rce r ula ' ns per the Cupertino Municipal Code, Section
918. ` r
Signature ✓ Date /1
❑ OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons:
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
construct the project (Sec.7044, Business & Professions Code).
I hereby affirm under penalty of perjury one of the following three
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.
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
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
become subject to the Worker's Compensation provisions of the Labor Code, I must
forthwith comply with such provisions or this permit shall be deemed revoked.
Sq. Ft Floor Area: I Valuation: $1400
APPLICANT CERTIFICATION
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
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
costs, and expenses which may accrue against said City in consequence of the
granting of this permit. Additionally, the applicant understands and will comply
with all non -point, source regulations per the Cupertino Municipal Code, Section
918. F,
Date
APN Number: 35922017 00 I Occupancy Type:
PERMIT EXPIRES IF IS NOT STARTED
WITHIN 180 T ISSUANCE OR
180 DAYS FR CALLED INSP ON.
Issued by: Date:
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.
Signature of Applicant: Date:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
HAZARDOUS MATERIALS DISCLOSURE
I have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533, and 25534. I will
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
Health & Safety Code, Section 25532(a) should I store or handle hazardous
material. Additionally, should I use equipment or devices which emit hazardous
air contaminants as defined by the Bay Area Air Quality Management District I
will maintain compliance with the Cupertigo Municipal Code, Chapter 9.12 and
the Health & Safety Code, Sections 2550515 33, and 25534. n
Owner or authorized agent: /f Date: i/
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of
work's for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
Lender's Address
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Licensed Professional
CUPERTINO
GENERAL PERMIT APPLICATION
MEP
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228 • FAX (408) 777-3333 • building(ftupertino.org v MISIC
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PROJECT ADDRESS
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APN # 35122
OWNER NAME AA�
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❑ OWNER ❑ OWNER -BUILDER ❑ OWNER AGENT
CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME
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LICENSE NUMBER
LICENSE TYPE
BUS. LIC #
COMPANY NA
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ARCHITECTXNGINEER NAME
LICENSE NUMBER
BUS. LIC #
COMPANY NAME
E-MAIL
FAX
STREET ADDRESS
CITY, STATE, ZIP
PHONE
USE OF ❑ SFD or DUPLEX P bIUL-7PI-FAMILY
PROJECT IN WII-DLAND ❑ YES
PROJECT IN ❑ YES
IS THE BLDG AN ❑YES
BUILDING: El COMMERCIAL
URBAN INTERFACE AREA NO
FLOOD ZONE NO
EICHLER HOME?
DESCRIPTION OF WORK
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TOTAL VALUATION:GD�3it
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By my signature below, I certify to each of the following: I the property owner or authorized agent to act on the property owner's behalf. I have read this
application and the information I have provide is co
the Description of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating to building nst
thor a representatives of Cupertino to enter the above -identified p perty i, s e o purposes.
Signature of Applicant/Agent:
Date: U/1
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SUPPLEMENTAL INFORMATION REQUIRED
OVER TH><COTJNTER
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IP AJOR1 11
MEPMiscApp_2011.doc revised 06/21/11
CITY OF CUPERTINO
FEE ESTIMATOR - BUILDING DIVISION
ADDRESS: 7620 KIRWIN LN DATE: 04/08/2015 REVIEWED BY: MENDEZ
APN:
BP#: *VALUATION: $1,400
*PERMIT TYPE: Electrical Permit Es PLAN CHECK TYPE: Alteration / Addition / Repair
PENTAMATION 1
PRIMARY SFD or Duplex PERMIT TYPE:
USE:
WORK 1 125 AMP PANEL UPGRADE
SCOPE
APPLIANCE / EQUIP TYPE FEE ID QTY UNITS BP FEES
Services 1 ERT<200 125 Amps $48
$48.00
TOTALS:
L1c�c h flan Check c k
Plumb. Plant Chc ( Elec. Plan Check 0.0 hrs $0.00
Llec;h. Permit Fi:c>.:
Plumb. Permit Tee: Elec. Permit Fee. lEPERMIT
otherr� mech. Ins'.
tJfhf°r Plumb Insp. Other Elea Insp. 0.0 hrs $48.00
Mech. In.�p. Fee P7urnb. hrsh. T ee:
Elec. Inrp, Fee:
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 the preliminaryinformation available and are onlyan estimate Contact the Det MISC ITEMS or addn'l info.
FEE ITEMS (Fee Resolution 11-053 Eff. 7/1/13) FEE QTY/FEE
Plan Check Fee:
Suppl. PC Fee
PME Plan Check: $0.00
Permit .Fee:
Suppl. h7sp Fee
PME Unit Fee: $48.00
PME Permit Fee: $48.00
f'onstruction Tar.
Administrative Fee:
IADMIN
$45.00
Work Without Permit?
® Yes � No
$0.00
Advanced Plirnning Fees:
Travel Documentation Fee:
1TRAVDOC
$48.00
$0.50
Select an Administrative Item
Strom Motion Fee:
IBSEISMICR
Bldg Stds Commission .Fee_
1BCBSC
$1.00
gg
$0.006
M' SEE $190.50
',
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$190.50
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Revised: 04/01/2015