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15070178WA CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 21384 DEXTER DR CONTRACTOR: SANTA CRUZ WESTSIDE PERMIT NO: 15070178 ELECTRIC OWNER'S NAME: ROB & LAURA TSUK 2119 DELAWARE AVE DATE ISSUED: 07/24/2015 OWNER'S PHONE: 4088354218 SANTA CRUZ, CA 95060 PHONE NO: (831) 469-8888 LICENSED CONTRACTO 'S DECLARATIO JOB DESCRIPTION: RESIDENTIAL Ej COMMERCIAL License Class Lic.#Contractor INSTALL NEW 125 AMP PANEL IN (E) LOCATION 3�l %A 4R0 kJ Ay"Cl'late1 Wolchapter hereby affirm that I am licensed under the prov (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: $2500 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: 32641068.00 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 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 WS FROM LAST CALLED INSP TI N. 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 Issued by: Date: with all non -point source regulation per the Cupertino Municipal Code, Section RE -ROOFS: 9.18. 7Z-7 / Signature DateAll 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) 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. I have and will maintain Worker's Compensation Insurance, as provided for by will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Sections 2550 255J3, a 5534. Section 3700 of the Labor Code, for the performance of the work for which this d Owner GDate: 7 2 T IS permit is issued. or authorized agent: 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 indemnify and keep harmless the City of Cupertino against liabilities, judgments, ARCHITECT'S DECLARATION 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 MEP��(�- COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 • buildino(a�cupertino.orQ M 5 (; ❑ PLUMBING ❑ MECHANICAL MELECTRICAL ❑ MISCELLANEOUS PROJECT A'RE$S� � �- // i APN o O\VNERNAMP DS S J r% I PHO 0 8�gy Z/ E2,LAIL STREET,M- ITY, ST9TE,ZI�� ,•_ /V Vl FAX `� C \ �iM _Q K�-��L ��-+• PiO STRE S \ I dJ �r i� /J C%r ,/ r e n��V CITY�A 7�IP ,1-il 4 t r Z L /� Y� �A ' E3ow.,,TR 13OWN'ER-BUILDER ❑ OWNER AGEI.'T 11CONN'TRACTOR 13COI.7RACTOR AGENT 11ARCH7ECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CO CTOR :A �� i` DC 'LICE? G3E�q1 C LICENSEME /� BUS. LIC t3 COMP.AI.rY N.ANE EF- EMAIL L c AS � �A C SA4 ` 3 P- FAX t L ` �( C-R► fl3 i sus �8 iC ST '-� 7 iL(Sf Ei A FW qI PH (p 00 L9 �JAZrA �� 64TE ZIP 570(02 5 ARCHITECTIENGINEER NAME LICENSE NUMBER BUS. LIC n CONIPAN'Y NAME E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE USE OF ❑ SFD or DUPLEX MULTI-FAMII,Y PROJECT IN WILDLAN'D ❑ YES PROJECT IN ❑ YES IS THE BLDG AN ❑ YES BUILDING: ❑ COMMERCIAL URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑ NO EICHLER HOME? ❑ NO DESCRIPTION OF WORK ( (? / kA Q C- ` L _ ��zr C �-- Acj �C T6 ! Z TOTAL VALUATION: RECEIVED`B] Va By my signature below, I certify to each of the following: I am the property owner or authorized agent to act on the pr pe ty owner's behalf. I have read this application and the information I have provided is correct. I ve read the Description of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating to buildinq con ction autho epresentatives of Cupertino to enter the above -i entifiedrop rty``fo�ection purposes. Signature of ApplicanUAgent: Date: , SUPPLEMENTAL II\TORMATION RE UIRED Q f EXPRESS �' <C� LARUE x x£ A,fEPA1iscApp_201 ].doe revised 06/21/11 CITY OF CUPERTINO 150q013f. FM --7 FEE ESTIMATOR — BUILDING DIVISION im,ADDRESS: 21384 Dexter Drive DATE: 07/24/2015 REVIEWED BY: Paul UNITS APN: 326 41 068 BP#: *VALUATION: 1$2,500 PERMIT TYPE: Electrical Permit PLAN CHECK TYPE: Alteration / Addition / Repair PRIMARY SFD or Duplex USE: Amps PENTAMATION 1 REAP PERMIT TYPE: WORK Install new 125 Amp Panel in E location SCOPE />rl. 177sp 1�,ee APPLIANCE / EQUIP TYPE FEE ID Phi nb. Plan Chcck QTY UNITS BP FEES Elec. Permit Fee: IEPERMIT Services 1 ERT<200 Other Elec. Insp. 0.0 hrs $48.00 125 Amps $48 Permit Fee: />rl. 177sp 1�,ee PME Unit Fee: $48.00 PME Permit Fee: $48.00 Construction Tcax: Administrative Fee: (ADMIN $45.00 Work Without Permit? Yes e) No $0.00 TOTALS: Travel Documentation Fee: ITRA VDOC 1 $48.00 Strong; Motion Fee: IBSEISMICR NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School District, etc.). These fees are based on the preliminary information available and are only an estimate. Contact the Dept for addn'l info. FEE ITEMS (Fee Resolution 11-053 Eff 7/1.'13) Meeh. Playa Check Phi nb. Plan Chcck Elec. Plan Check 0.0 1 hrs $0.00 ;blech_ M,rmit Fees Elec. Permit Fee: IEPERMIT Other Alech. InsP z 1, -, 1'.rELI Other Elec. Insp. 0.0 hrs $48.00 PME Plan Check: $0.00 NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School District, etc.). These fees are based on the preliminary information available and are only an estimate. Contact the Dept for addn'l info. FEE ITEMS (Fee Resolution 11-053 Eff 7/1.'13) FEE QTY/FEE MISC ITEMS Plan Check 1 'ee: Suppl. PC Fee PME Plan Check: $0.00 Permit Fee: />rl. 177sp 1�,ee PME Unit Fee: $48.00 PME Permit Fee: $48.00 Construction Tcax: Administrative Fee: (ADMIN $45.00 Work Without Permit? Yes e) No $0.00 Advuncecl Planning 1''ees. Travel Documentation Fee: ITRA VDOC $48.00 Strong; Motion Fee: IBSEISMICR $0.50 Select an Administrative Item Bldp,Stds Commission Fee: IBCBSC $1.00 SUBTOTALS: $190.50 $0.00 TOTAL FEE: $190.50 Revised: 07/02/2015