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15040072CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 7671 ORANGE BLOSSOM DR CONTRACTOR: T J CONSTRUCTION & PERMIT NO: 15040072 DESIGN OWNER'S NAME: RITTENER PATRICIA J 167 S CLAREMONT AVE S DATE ISSUED: 04/09/2015 OWNER'S PHONE: 9197178922 SAN JOSE, CA 95127 PHONE NO: (408) 506-2828 ❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL COMMERCIAL AMP PANEL UPGRADE �*200 License Class +, — y Lie.# 2 1-3 G Contractor 7 _T(Opq-�CAJI10— Date 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 pensation, as provided for by Section 3700 of the Labor Code, for the erformance of the work for which this permit is issued. Sq. Ft Floor Area: Valuation: $1500 I have and will maintain Worker's Compensation Insurance, as provided for by APN Number: 36611083.00 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 F , LAST 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 Issued by: Date: Cl granting of this permit. Additionally, the applicant understands and will comply with all non -point so regulations per the Cupertino Municipal Code, Section RE -ROOFS: All roofs shall be inspected prior to any roofing material being installed. If a roof is 918. g Signature Date 7% '� (—l� installed without first obtaining an inspection, I agree to remove all new materials for inspection. ❑ ER -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 25505,5533, and 25534. 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 COMMUNITY DEVELOPMENT DEPARTMENT - BUILDING DIVISION 10300 TORRE AVENUE - CUPERTINO, CA 95014-3255 (408) 777-3228 - FAX (408) 777-3333 - building(c-Dwoertino.org e F-1 TvTTSC`FT .T .A WF.(_)I TS MEP MISC UPLUM131NCi LJmJ �nHivn rw u• •• ••------_-� PROJECT ADDRESS APN OWNER NAME PHONEE-MAIL �+- 22 STREET ADDRESS CITY, STATE, ZIP FAX CONTACT NAME --- PHONE E-MAIL STREET ADDRESS CITY, STATE, ZIP FAX ❑ OWNER ❑ OWNER -BUILDER ❑ OWNER AGENT I CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME.__ LICENS NUMBER LICENSE TYPE BUS. LIC # —2 Z � _o COMPANY NAME-- SA U C_r , Go t4e2 E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE 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 PROJECT IN WILDLAND ❑ YES PROJECT IN ❑ YES IS THE BLDG AN ❑ YES ❑ NO BUILDING: ❑ COMMERCIAL URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑ NO EICHLER HOME? DESCRIPTION OF WORK nn r y/ !`^ 'ns s2r yW. 5h'4x y4. TOTAL VALUATION: ELYED9Y yxr x ^ O By my signature below, I certify to a ch 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 with all applicable local ordinances and state laws relating to building nstruction. rize representatives of Cupertino to enter the above -identified property for inspection purposes. Signature of Applicant/Agent: Date: INFORMATION REQUIRED OFFICE TJSE ONLY TF S1*ffLgJvMNTAL , OVER TH><COUNTER r �Qgip..� t �G , sP „. ° ❑ MAJUR h MEPMiscApp_2011.doc revised 06/21/11 „��, CITY OF CUPERTINO IAM7 FFP. F.CT11%/FAT0R — RITII.DING DIVISION 19' ADDRESS: 7671 orange blossom ave FEE ID DATE: 04/09/2015 REVIEWED BY: Mendez APN: BP#: *VALUATION: 1$1,500 *PERMIT TYPE: Electrical Permit PLAN CHECK TYPE: Alteration / Addition / Repair PRIMARY SFD or Duplex $48 Plumb. Permit Fee: PENTAMATION 1 REAP2 USE: Plumb Trisp. LLJ Other Elec. Insp. hrs $48.00 0.0 PERMIT TYPE: i Plumb, Trisp. Fee: k°lec. Inst, Fee: PME Unit Fee: WORK 12oo amp panel upgrade $48.00 : Construction Tax: SCOPE Administrative Fee: ]ADMIN APPLIANCE / EQUIP TYPE FEE ID III ' QTY UNITS BP FEES Services 1 ERT<200 Nkch, Plan Check 200 Amps $48 Plumb. Permit Fee: Elec. Permit Fee: IEPERMIT A,kc/r. Insp.(Jitter• Plumb Trisp. LLJ Other Elec. Insp. hrs $48.00 0.0 1derti. ]rasp. Fee: Plumb, Trisp. Fee: k°lec. Inst, Fee: PME Unit Fee: $48.00 PME Permit Fee: $48.00 : Construction Tax: Administrative Fee: ]ADMIN $45.00 Work Without Permit? ® Yes (E) No $0.00 TOTALS: i �s $4800 r t+ , '”" .� -a- M-1; 9 ., a9 r Eno III ' y1 Plan Check h'ee: .0 8.!c. Stippl—p("` I'ee Nkch, Plan Check Plumb_ Plan Cheek Elec. Plan Check 0.0 hrs $0.00 :Clea/r. Permit Fere: Plumb. Permit Fee: Elec. Permit Fee: IEPERMIT A,kc/r. Insp.(Jitter• Plumb Trisp. LLJ Other Elec. Insp. hrs $48.00 0.0 1derti. ]rasp. Fee: Plumb, Trisp. Fee: k°lec. Inst, Fee: NOTE: This estimate does not include fees due to other Departments (t.e. rianntng, ruotic rwortcs, rtre, aunttury newer 1, —, LLvu, fha nrol;Lssinnnr infnrmatinn availahle and are only an estimate. Contact the Dept for addn'l info. FEE ITEMS (Fee Resolution 11-053 E(. 7/1/13) FEE QTY/FEE MISC ITEMS Plan Check h'ee: Stippl—p("` I'ee PME Plan Check: $0.00 1'eNmtt SatppL Ins[) P'ee PME Unit Fee: $48.00 PME Permit Fee: $48.00 : Construction Tax: Administrative Fee: ]ADMIN $45.00 Work Without Permit? ® Yes (E) No $0.00 ,ldvanced Planning fees: i Travel Documentation Fee: ITRAVDOC $48.00 Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item Bldg Stds Commission .Fee: IBCBSC $1.00 $190.50 $0.00 14��?�F $190.50 Revised: 04/01/2015