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15070013 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 2182� LOMITA AVE CONTRACTOR:K&M DEVFLOPMENT PERM1IIT NO: 15070013 INC OWNER'S NAM1IE: 21815 LOMITA AVE LLC 20874 HANFORD DR DATE ISSUED:07/02/2015 OWNER'S PHONE: 4083905127 CUPERTWO,CA 95014 PHONE NO:(408)390-5127 ❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDF,NTIAL � COMMERCIAL � / INSTALLATION OF TEMP POWER(100 AMP). License Class � Lic.# ��f"� �� Contractor ,��' /�� D�G 7 � T I hereby aftirm that 1 am licensed under the provisions of hapter 9 (commcncing 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 nvo declarations: I have and will maintain a certificate of consent to self-insure t�or 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: �'aluation:$i00 I have and will maintain Worker's Compensation Insurance,as provided Tor by Section 3700 of the Labor Code,for the performance of the work for which this APN Number:35716061.21825 Occupancy Type: permit is issued. APPLICANT CERTIFICATION t certify that I have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED correct. 1 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 FROM 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 ��„/ �--, `� 7 .� _� granting of this permit. Additionally,the applican[understands and will comply Issued by: 1 V f�j��t Date: with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. � 2 f� RE-ROOFS: Si e Date All roofs shall be inspected prior to any rooting material being installed. lf a roof is installed without first obtaining an inspection,1 agree ro remove all new materials Yor inspection. ❑ O«'NER-BUILDER DECLARATION Signature oY Applicant: Date: 1 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[he 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) l,as owner of the property,am exclusively contracting with licensed contractors ro HA7,ARDOUS�TATERIALS DISCLOSI�RE 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 1 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 deviccs which emit hazardous Compensation,as provided for by Section 3700 of the Labor Code,for the air contaminants as deTined 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�1unicipal Code,Chapter 9.12 and I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sections 2 ,25533,and 25534. � Section 3700 of the Labor Code,for the performance of the work for which this �s permi[is issued. Owner or authorize Date: 1 certify that in the performance of the work for which this permit is issued,1 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,1 CONSTRUCTION LENDING AGENCY become subject to the Worker's Compensation provisions of the Labor Code,I mus[ I hereby�aftirm that there is a construction lending agency for[he 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 CERTIFIC:ITION Lender's Address I certify that 1 have read this application and state that the above inYormation is corcect. I agree to comply�vith all city and county ordinances and state laws relating to building construction,and hereby authorize representatives of this city[o enter upon the above mentioned property for inspection purposes.(We)agree to save .aRCHITECT'S DECLAR:�TION 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 PER�I�[IT APPLICATION fi COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION � 10300 TORRE AVENUE• CUPERTINO, CA 95014-3255 (408)777-3228 • FAX(408)777-3333 • buildino(a�cupertino.orq 1/rjU �/ � +CUPERTtNta (L� �li�i(3 ❑PLUMBING ❑MECHAMCAL r LECTRICAL ❑MISCELLANEOUS PROIECT ADDRESS 7/�� /, ^ �� .APN R G �'�� O\�"1�ERNAME PHO E-M.AIL )L �// ,9� �1� ��h/G' �cS �� S/Z •�.,-��,rT�Jq�t � , STREET.ADDRESS CITY, STATE,ZIP FAX ' o -� h` ' �� Ce.r7t i-� 7'S�� COI�'T.ACT NANfE�� f�n_ /� PHO:�'E E-?vL4IL �„��rr r� STREET ADDRESS CITY,STATE, ZIP FAX OR?.'ER ❑ OR'2�'ER-BUII.DEFt ❑ OW?�TERAGE'�'T ❑ CO?.'TRACTOR ❑COA�IRACTORAGcNT ❑ ARCHITECT ❑E*;GL'.'EER ❑ Dt��ELOPER ❑ TE\A2.'T COh'TRACTO rAh� LICENSE R LICEI�' TYPE BliS.LIC�' ��'-�z�i�-lC -�G �� . � CON 0.2vY 1�'AME E-MAIL FAX 2 y/� � STR.EET ADDRESS CITY,STATE,ZIP P .'$� �3 a�� ARCHITECT/ENGII��ER hANE LICEt�'SE I�'tJMBER BUS.LIC f COMPAtv'Y T`.AME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHOI�E USE OF �SFD or DLPLEX ❑ ?vIULTI-F?J�ffi.Y PROJECT LN WII.DLAh� ❑ YES PROJECT IN ❑ YES LS THE BLDG AN ❑ YES BUIL.DL�'G: �COMMERCLAL URBAN INTERFACE AREA NO FLOOD ZOr'E r0 EICHLER H0:�4E? '0 DESCRIPTION OF WORK �� o�z-�, i vD �M� TOT.AL VALUATION: �� '�- RECEIVED BY: . � � ; .,.?�.�,�., �.>,.. By iny si�nature below,I certify to each of the follo«�in�: I a�n the property o�a�ner or authorized a�ent to act on the property o��ner's behalf. I have read this application and tl�e inforu�ation I have provided is correct. I have read the Desciiption of\T��ork and��erify it is accurate. I a�ree to comply«ith all applicable local ordinances and state laws relatin�to buildin�constructi . I authorize representatives of Cupertino to enter the above-identified roperty for inspection pur��oses. SijnatureofApplicandA�ent: — Date: � Z �S AL N QUIRED �� orFic� t;sr_b��L� � �ovr.r.-�r�ie-co��rr_E� r ❑ f.�rtir�s - ❑ sr,a'�i�:�[�n � � L 1RGF. � i_; n1:SJOR � R7EPMiscApp_2011.doc i•ei�ised 06/21/11 CITY OF CUPERTINO FEE ESTIMATOR- BUILDING DIVISION ADDRESS: 21825 Lomita Ave DATE: 07/02/2015 REVIEWED BY: Sean APN: BP#: � r'f� `VALUATION: $500 °PERMIT TYPE: Electrical Permit PLAN CHECK TYPE: Alteration /Addition / Repair PRIMARY PENTAMATION USE: SFD or Duplex PERMIT TYPE: 1 REAP1� wolt�c Installation of tem ower 100 am . SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Temporary Power 1 ERT<200 100 Amps $48 TOTALS: $48.00 Elec. Plan Check 0.0 hrs $0.00 Elec. Permit Fee: IEPER.A�fIT � �,�F�, � Other Elec. Insp. 0.0 hrs $48.00 NOTE: This estimate does not include jees due to other Depnrtments(i.e. Planning,Public Works, Fire,Sanitary Sewer District,School District,etc. . These ees are based on the relimina in ormation available and are onl an estimate. Contact the De t or addn'1 in o. FEE ITEMS (Fee Resolu�ion 1/-0�3 E�:f 7%�I��13t FEE QTY/FEE MISC ITEMS PME Plan Check: $0.00 PME Unit Fee: $48.00 PME Permit Fee: $48.00 Administrative Fee: I,�DMlN $45.00 Work Without Permit? � Yes � No $0.00 Travel Documentation Fee: 17'�1 vooC $48.00 � Stron� Motion Fee: IBSE/SMICR $0.50 Select an Administrative Item Bld� Stds Commission Fee: 1BCBSC $1.00 SUBTOTALS: $190.50 $0.00 TOTAL FEE: $190.50 Revised: 07/01/2015