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15040075 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10282 NI EMHART LN CONTRACTOR:D&D CONSTRUCTION PERMIT NO:15040075 AND DEVELOPMENT OWNER'S NAME: BROBERG ROBERT NEAL III AND SAN W PO BOX 3565 DATE ISSUED:04/09/2015 OWNER'S PHONE: 4087720715 FREMONT,CA 94539 PHONE NO:(510)579-2353 ❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL E] COMMERCIAL E] INSTALL TEMP POWER License Class,_ Lic. Contractor --Sw I\) X— Date I 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 Valuation:$500 performance of the work for which this permit is issued. Sq.Ft Floor Area: 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:37517016.00 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 WIT�T �S[8 PERMIT ISSUANCE OR to building construction,and hereby authorize representatives of this city to enterupon the above mentioned property for inspection purposes. (We)agree to save 180DAF AST CALLED INSP CTION. indemnify and keep harmless the City of Cupertino against liabilities,judgments, v costs,and expenses which may accrue against said City in consequence of the Issued by: Date: ) 'l o 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. _ RE-ROOFS: Signature_ Date Q LA 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 ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER 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) HAZARDOUS MATERIALS DISCLOSURE I,as owner of the property,am exclusively contracting with licensed contractors to 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 air contaminants as defined by the Bay Area Air Quality Management District I Compensation,as provided for by Section 3700 of the Labor Code,for the will maintain compliance with th Cupertino Municipal Code,Chapter 9.12 and performance of the work for which this permit is issued. the Health&Safety Code,Sectio 25 5,25533,and 25534. 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 Owner or authorized agent: Date� R 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 I hereby affirm that there is a construction lending agency for the performance of become subject to the Worker's Compensation provisions of the Labor Code,I must work's for which this permit is issued(Sec.3097,Civ C.) forthwith comply with such provisions or this permit shall be deemed revoked. 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 918. Signature Date GENERAL PERMIT APPLICATION MEP COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 CIJPERTINQ (408)777-3228•FAX(408)777-3333•buildinga_cupertino.org MISC ❑PLUMBING ❑MECHANICAL ELECTRICAL ❑MISCELLANEOUS PROJECT ADDRESS ,,4 ,.r-f- L APN# 3 75 1-7 016 O E NAM PHONE `j72 E-M IL 1 ro�c1- rHa, , cCs STREET ADDRESS vl Ie.- C-4 CITY,STATE�ZIP F -_ Ty: �o e A-Olrol CONTACT NAME �O' ( , ( v PHONE �1 10 fiQ E-MAIL STREET ADDRESS O!�C IoV��Jlt'/ CITY,STATE,ZIP FAX ❑OWNER ❑ OWNER--BUB-DER ❑ OWNER AGENT CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT CONTRACTOR NAME-c+1 /\- -,�w V 1.%_ LICENSE NUMBER Z LICENSE TYPE jrj BUS.LIC# COMPANY NAM /�� b � E-MAIL r FAX STREET ADDRESS V t CITY,STATE,ZIp✓ _ L +J PHONE y t 0- ARCHITECT/ENGINEERNAME LICENSE NUMBER BUS.LIC# COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE USE OF Dor DUPLEX ❑ MULTI-FAMILY IN WILDLAND ID YES PROJECT IN ❑YES IS THE BLDG AN ❑YES BUILDING: COMMERCIAL URBAN RMRFACE AREA �NO FLOOD ZONE I&NO EICHLERHOME? If NO DESCRIPTION OF WORK TOTAL VALUATION: �W '� '�; .; 'a�. 'rl� -� v � By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on the prope is 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 uildin onstruction )I e r fives f Cupertino to enter the above-identified property for inspection purposes Signature of Applicant/Agent: `�$ �+ /,C �+—� Date:SUPPLEMENTAL INFORMATION REQUIRED R Q E f - .?OFFICLEUSEONLYS _., W OVER THE COUNTER W ti �EXPRESS�„,�u 'p, Y�� 61 U ., STAI3DARD" 1 Skd4 ' y MEPMiscApp_2011.doc revised 06/21/11 CITY OF CUPERTINO FEE ESTIMATOR-BUILDING DIVISION ADDRESS: 10282 menhart In DATE: 04/09/2015 REVIEWED BY: Mendez APN: BP#: *VALUATION: $500 *PERMIT TYPE: Electrical Permit PLAN CHECK TYPE: Alteration/Addition/ Repair PRIMARY PENTAMATION 1 REAP14 USE: SFD or Duplex PERMIT TYPE: i WORK install temp power SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Temporary Power 1ERT<200 1 Amps $48 TOTALS: $48.00 y ,.{_ -�'{e�t "I'M tla�ch 1'l�zn Check 1'Iauub. flan Check Elec.Plan Check 0.0 hrs $0.00 Mech. Permil Fee: Plumb.Permit Fee: Elec.Permit Fee: IEPERMIT L Insp_ E171- Other Plum) Insp. Li Other Elec.Insp. 0.0 hrs $48.00 ech. h1q). Fee: Plumb, hasp. Fee: Ilec.Insp. Fee: NOTE:This estimate does not include fees due to other Departments('tie.Planning,Public Works,Fire,Sanitary Sewer District,School District,etc). These fees are based on the prelimina information available and are only an estimate. Contact the Dept-for addn'l info. FEE ITEMS (Fee Resolution 11-053 Ef. 7/1/13) FEE QTY/FEE MISC ITEMS Plan Check Pee: Sb1f)/)t. .PC'I"e(' PME Plan Check: $0.00 1'errnit Fee: szappL Irasp Pee PME Unit Fee: $48.00 PME Permit Fee: $48.00 C%®nstruction Tax: Administrative Fee: 1ADMIN $45.00 Work Without Permit? 0 Yes (E) No $0.00 .2clvaneecl Planning fees: Travel Documentation Fee: ITRA VDOC $48.00 Strom Motion Fee: IBSEISMICR $0.50 Select an Administrative Item Bldp-tds Commission Fee: IBCBSC $1.00 $190.50 $0.00 ,r LFE� $190.50 A e f� _�.b tlNSI.�"+ Revised: 04/01/2015