15040046 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 21958 OAKDELL PL CONTRACTOR:DALCON,INC. PERMIT NO:15040046
OWNER'S NAME: KWONG BENJAMIN AND ROBIN 757B CHESTNUT ST DATE ISSUED:04/07/2015
OWNER'S PHONE: 4082551957 SAN JOSE,CA 95110 PHONE NO:(408)298-1690
LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL COMMERCIAL
p, UPGRADE(E)150 AMP PANEL TO 200 AMP,SAME
License Class C, Q Lic.It Z ` �' LOCATION
Contractor Date 7
I hereby affirm that 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:$6000
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:32618047 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 WITIIIN 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 DA L CALLED 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
granting of this permit. Additionally,the applicant understands and will comply ssu Date:
with all non-point source regulations per the Cupertino Municipal Code,Section
9 18.
j__—q
� RE-ROOFS:
Signature Date 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 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
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 o MEP
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION �O
10300 TORRE AVENUE•CUPERTINO,CA 95014-3255 MISC
GUPERTINO (408)777-3228•FAX(408)777-3333•buildinq(@-cuper ino.org
❑PLUMBING ❑MEECH'A`NICAL ELECTRICAL ❑MISCELLANEOUS
PROJECT ADDRESS L. APN#
OWNERNAME vw1� PHONE CC/ot� �C,s�- JC 55 E-MAIL
STREET ADDRESS �'7( oa r�n" ` CITY, STATE,ZIP ��l CA -1'5o 14 FAX
CONTACT NAME C•1iz rte PHONE(VOI -7 11-9 1 r 0 E-MAIL
STREET ADDRESS / w` c/ S ��\[C`3 CITY,STATE,ZIP C_ l ,e,G� Rci I o FAX
13 OWNER 11 OWNER-BUILDER ❑ OWNER AGENT CONTRACTOR ❑CONTRACTOR yAGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT
CONTRACTOR NAME \ �1 \ _� LICENSE NUMBERS$Z9`� LICENSE TYPE l;1 BUS.LIC#
COMPANY NAMEt �� PIJS ;` E-MAIL FAX
STREET ADDRESS l�—I �.1 _.►�,_SIC . "' CITY,STATE,ZIP 5kr�e jG� cW U PHONE /�0�,z7.�I w�,
ARCHITECT/ENGINEER NAME l/1"r'"`",y��'iii►►i""""ii„" LICENSE NUMBER BUS.LIC#T
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF ❑SFD or DUPLEX ❑ MULTIFAMILY PROJECT IN WILDLAND ❑ YES PROJECT IN ❑YES IS THE BLDG AN ❑YES
BUILDING. ❑COMMERCIAL URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑NO EICHLER HOME? ❑NO
DESCRIPTION OF WORK ® Z a0 f
TOTAL
VALUATION: a�(�c7�
By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on th 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 acc rate. I agree to comply with all applicable local
ordinances and state laws relating to building=t' n. I orize representatives of Cupertino to enter the above-id ifi�d property for inspection purposes.
Signature of Applicant/Agent: Date: Li// ((///
SUPPLE NTAL INFORMATION REQUIRED �� oFa 5
usE oi�rtx ���
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MEPMiscApp_2011.doc revised 06/21/11
CITY OF CUPERTINO
FEE ESTIMATOR—BUILDING DIVISION
ADDRESS: 21958 OAKDELL PL' DATE: 04/07/2015 REVIEWED BY: MELISSA
APN: 326 18 047 BP#: -VALUATION: 1$6,000
*PERMIT TYPE: Electrical Permit PLAN CHECK TYPE: Alteration/Addition / Repair
PRIMARY SFD or Duplex PENTAMATION 1 REAP2
USE: p PERMIT TYPE: i
WORK UPGRADE E 150 AMP PANEL TO 200 AMP SAME LOCATION
SCOPE
APPLIANCE/EQUIP TYPE FEE ID, QTY UNITS BP FEES
Services 1ERT<200 200 Amps $48
TOTALS:
$48 00
� rr a r r _
_k 1211 It
Afech. Plan Check Plumb. Plary Check Elec.Plan Check 0.0 hrs $0.00
F11h Permil Fee: Plumb. Permit Fee: Elec.Permit Fee: IEPERMIT
Aleck. Trap, Other Plumb Insp. Other Elec.Insp. 0.0 hrs $48.00
tlech. 111sp. Fee: Plumb. Insp. Fee: f-lee.Insp,Fee:
NOTE: This estimate does not include fees due to other Departments(Le,Planning,Public Works,Fire,Sanitary Sewer District,School
District,eta). These fees are based on the prelimina information available and are only an estimate. Contact the De t or addn I info.
FEE ITEMS(Fee Resolution 11-053 E . 7/1/13) FEE QTY/FEE MISC ITEMS
Plan Check P'ee:
.1,1j,)pl. .P(,PIT
PME Plan Check: $0.00
Permit F'ee:
slfj,pl. I.nsr Pee.
PME Unit Fee: $48.00
PME Permit Fee: $48.00
Construclion Tax:
Administrative Fee: IADMIN $45.00
Work Without Permit? ® Yes (E) No $0.00
Advanced Planning Fees:
Travel Documentation Fee: ITRAVDOC $48.00 i
Strong Motion Fee: IBSEISMICR $0.78 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $1.00
$190.78 $0.00a b ,
w $190.78
Revised: 02/14/2015