15080034A
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 7576 KIRWIN LN
CONTRACTOR: MAINE ELECTRIC INC
PERMIT NO: 15080034
OWNER'S NAME: PACIFIC AUTISM CENTER
599 LEISURE ST
DATE ISSUED: 08/05/2015
OWNER'S PHONE: 4082215806
LIVERMORE, CA 94551
PHONE NO: (925) 443-3377
LICENSED CONTRACTOR'S DECLARATION
JOB DESCRIPTION: RESIDENTIAL E] COMMERCIAL
REPLACE (E) 125 AMP PANEL & INSTALL 2 (N)
License Class G 1 Lic. # 3 o Z O
DEDICATED CIRCUITS
L��iT
ContractorW` 1'00 G C. 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
Compensation, as provided for by Section 3700 of the Labor Code, for the
Sq. Ft Floor Area:
Val nation: $5270
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: 35922025.00
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 LED 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
g/s
granting of this permit. Additionally, the applicant understands and will comply
ate:
with all non -point source regulations per the Cupertino Municipal Code, Sec ' n
9.18.
,��}�
ko Q' `1
RE -ROOFS:
Signature; �'^r Date
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
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)
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 2550,51,, 25533, and 25534.
Section 3700 of the Labor Code, for the performance of the work for which this
Owner or authorized agenAL—K �n��1�0 W V 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
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 (See. 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
GENERAL PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
MEP
UI 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 misc
CUPERTII+10 ( (408) 777-3228 • FAX (408) 777-3333 • building(cDcupertino.org /)
❑ PLUMBING ❑MECHANICAL MELECTRICAL ❑ MISCELLANEOUS
PROJECT ADDRESS i
APN tl
OWNER NAME C 1 V
PHiO(V �v2
E-MAIL
STREET ADDRESS\ t/jry hGH CITY. STATE 7[P n / FAX
CONTACT NAME r. S PHONE rj zs 1 _ L, 10 3 E-7
J i
STREET ADDRESS
C[TY, STATE, ZIP
FAX
❑ wNF, ❑ OWNER -B iuDER. 13 oWNERAau4T CONTRACTOR ❑CONTRACTORAGENT ❑ ARcHr ECT ❑ ENGIIdEER ❑ DEYELOPFR ❑ TENANT
CONTRACTOR NAME I
LICENSE NUMBER r! 30 3 S U
LS
LICENSE TYPE L 1 U
BUS. LIC #
COMPANY NAME
E-MAIL
FAX
MEET ADDRESS �jr1 L e. t s o�
CrrY. STATE, z1P 9 VS S /
Luse-rruv�
1' f 3 -3 3 -7 7
ARCIi MMENGINM NAME
LICENSE NUMBER
BUS. LIC #
COMPANY NAME
E-MAIL
FAX
STREET ADDRESS
CITY. STATE, ZIP
PHONE
USE OF C9 SFD or DUPLEX ❑ MULTI -FAMILY
BUILDING 13COMMERCIAL
PROJECT IN WJLDLAND ❑ YES
URBAN INTERFACE AREA [3NO
T��E71N [3YES
ZONE ❑ NO
IS THE BLDG AN ❑ YES
MCM.ER HOME? ❑ No
DESCRIF17ON OF WORK
7Le. �ac�-e, i�S I>�a►,� F�al��! ► fall �U n� 1 V � c%�rcu,t' {ter
lnl�IC,r0WTLue- au`d 5(r m ��2�lJv CcicLLt� �'o� Stvu(L
TOTAL VALUATION: 5 a, / vBy
try signature below, I certify to each of the following: I mn the property owner or authorized ajWt to act on the property s read this
application and the mforam m I ban provided is correct I have read the Description of Work and verify it is accur ft with all applicable local
ordinances and state laws relating to bud d�ng motion I representatives of Cupertino to enter the aboveiden' red puTerty for inspection purposes.
Signature of Applicant/Agent: � Date:
SUPPLEMENTAL INFORMATION REQUIRED
OFFICE USE ONLY
4VEWTHliCOI MER
❑ 1?
❑ STANDARD
a
a
❑ LARGE
❑ MAJOR
A1UA iscApp 101bibcrevised 0621/11
CITY OF CUPERTINO
FEE ESTIMATOR - BUILDING DIVISION
APPLIANCE / EQUIP TYPE
ADDRESS: 7576 KIRWIN LN
DATE: 08/05/2015
REVIEWED BY: MELISSA
UNITS
APN: 359 22 025
BP#:
*VALUATION: 1$5,270
*PERMIT TYPE: Electrical Permit
PLAN CHECK TYPE: Alteration / Addition / Repair
PRIMARY SFD or Duplex
USE:
Amps
PENTAMATION 1 REAP2
I PERMIT TYPE: 19
WORK
REPLACE E 125 AMP PANEL & INSTALL 2 N DEDICATED CIRCUITS
SCOPE
atl�pl. Insp I'r>G
APPLIANCE / EQUIP TYPE
FEE ID
"!armb. Plan C" hecrc
QTY
UNITS
BP FEES
Elec. Permit Fee: I EPERMIT
Services
1 ERT<200
Other Elec. Insp. F6.61hrs $48.00
100
Amps
$48
Special Circuits
1 BREMMISC
atl�pl. Insp I'r>G
2
#
$286
PME Unit Fee:
$334.00
PME Permit Fee:
$48.00
onstruction Tax:
Administrative Fee: ]ADMIN
$45.00
Work Without Permit? Yes (F) No
$0.00
TOTALS:
Travel Documentation Fee: ITRA VDOC
$334.00
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 nreliminary information available and are only an estimate. Contact the Dept for addn7 info.
FEE ITEMS (Fee Resolutioiz 11-053 a.' 7/1/13)
11ech..Plceu Check
"!armb. Plan C" hecrc
Elec. Plan Check 0.0 hrs $0.00
114ec:h. Permit 1,'ee:
Phimb. Permit tee:
Elec. Permit Fee: I EPERMIT
truer A1ech. Insp.
=')cher Plumb hap.Li
Other Elec. Insp. F6.61hrs $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 nreliminary information available and are only an estimate. Contact the Dept for addn7 info.
FEE ITEMS (Fee Resolutioiz 11-053 a.' 7/1/13)
FEE
QTY/FEE
MISC ITEMS
an Check .Fee:
mppl. PC' Fee
PME Plan Check:
$0.00
rmit Fee:
atl�pl. Insp I'r>G
PME Unit Fee:
$334.00
PME Permit Fee:
$48.00
onstruction Tax:
Administrative Fee: ]ADMIN
$45.00
Work Without Permit? Yes (F) No
$0.00
�J� ancec/ Planning fi es:
Travel Documentation Fee: ITRA VDOC
$48.00
Strong Motion Fee: IBSEISMICR
$0.69
Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC
$1.00
SUBTOTALS:
$476.69
$0.00 TOTAL FEE:
$476.69
Revised: 07/02/2015