15040094�I
CITYOF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS:
LOS GATOS, CA 95032-2504
PHONE NO: (408) 835-2122
❑ LICENSED CONTRACTOR'S DECLARATION
JOB DESCRIPTION: RESIDENTIAL E] COMMERCIAL ❑
200 AMP PANEL UPGRADE; INSTALL (3) DEDICATED
# B$�Jd�
License Class',
CIRCUITS IN KITCHEN, (1) IN OFFICE
rLic.
l
Contractor 15(YK+k G LA*_C-Kt C Date 1'L - Lk — a"O 1,
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
Sq. Ft Floor Area:
Valuation: $750
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
APN Number: 37540017.00
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
WITHIN 180 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 CALLED INSPECTION.
rMA
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:
granting of this permit. Additionally, the applicant understands and will comply
int source regulations per the Cupertino Municipal Code, Section
with
;�Date
All roofs shall be inspected prior to any roofing material being installed. a roof
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
1, 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)
1, 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 wit a lCupertino Municipal Code, Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance, as provided for by
the Health & Safety
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
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
CITY OF CUPERTINO
FFF F'RTIMATOR — BUILDING DIVISION
I Meal?. Plan Cki eck
;Meeh. Pet•itrt Fee:
I Oiber Alcch. lrisp.
M1lerls. Insp_ Eec:
Plumb. Plata Check
Plumb. Permit I�ee:
Other Plumb Insp.
Phimb. Insp. Fee:
N
Elec. Plan Check 0.0 hrs $0.00
Elec. Permit Fee: ]EPERMIT I
Other Elec. Insp. 1 0.0 1 hrs 1 $48.00
I.rlec. Inst, Fee:
NOTE: This estimate does not include fees due to other Departments (/.e. Planning, Public worms, rise, sanitary,3ewer visrrict, acnooi
T:s..:..f „s.. 1 Tbnon Fnnn n..n l.nonil na iGn nrn/isninnru iafnrsnntinN nvni/OG/O OB/% 010 OK1V aK e.CtLiftatP_ Contact the Dent for addn'1 info.
FEE ITEMS (Fee Resolution 11-053 E . 7/1/13)
ADDRESS: 6189 shadygrove dr
DATE: 04/14/2015
REVIEWED BY: Mendez
APN:
BP#:
*VALUATION: $750
*PERMIT TYPE: Building Permit
PLAN CHECK TYPE: Alteration / Repair
PRIMARY
USE: SFD or Duplex
Suppl. PC Fee: E) Reg. ® OT
PENTAMATION
PERMIT TYPE: 1 REAP
WORK
200 amp panel upgrade; install 3 dedicated circuits in kitchen 1 in office
SCOPE
I Meal?. Plan Cki eck
;Meeh. Pet•itrt Fee:
I Oiber Alcch. lrisp.
M1lerls. Insp_ Eec:
Plumb. Plata Check
Plumb. Permit I�ee:
Other Plumb Insp.
Phimb. Insp. Fee:
N
Elec. Plan Check 0.0 hrs $0.00
Elec. Permit Fee: ]EPERMIT I
Other Elec. Insp. 1 0.0 1 hrs 1 $48.00
I.rlec. Inst, Fee:
NOTE: This estimate does not include fees due to other Departments (/.e. Planning, Public worms, rise, sanitary,3ewer visrrict, acnooi
T:s..:..f „s.. 1 Tbnon Fnnn n..n l.nonil na iGn nrn/isninnru iafnrsnntinN nvni/OG/O OB/% 010 OK1V aK e.CtLiftatP_ Contact the Dent for addn'1 info.
FEE ITEMS (Fee Resolution 11-053 E . 7/1/13)
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee:
$0.00
200 amps
$48.00
Electrical
IBELEC200 Services
Suppl. PC Fee: E) Reg. ® OT
0.0
hrs
$0.00
PME Plan Check:
$0.00
F 4
$48.00
Electrical
1BREMRECEP Recep/Switch/Outlets
Permit Fee:
$0.00
Suppl. Insp. Feer Reg. ® OT
0.0
1 hrs
$0.00
PME Unit Fee:
$0.00
PME Permit Fee:
$48.00
C'onslructlon Tax:
Administrative Fee: ]ADMIN
$45.00
0
0
Work Without Permit? ® Yes (j) No
$0.00
Advanced Planning Fee:
$0.00
Select a Non -Residential
Building or Structure
E)
0
i
Travel Documentation Fee: ITRA VDOC
$48.00
Strong Motion Fee: ]BSEISMICR
$0.50
Select an Administrative Item
Bldg Stds Commission. Fee: 1BCBSC
1 $1.00
`
$9600��1u1E
238.50
Revised: 04/01/2015