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15080209I CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 1198 ELMSFORD DR OWNER'S NAME: WOODS STANLEY P AND KATHLEEN W TRUS CONTRACTOI QBE P2—T LA ,—PERMIT NO: 15080209 Dc -i i &,O 4 40" STA 4.4 cr O DATE ISSUED: 08/28/2015 I OWNER'S PHONE: 4088737953 1 . I PHONE NO: I LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL [] COMMERCIAL ❑ UPGRADE (E) 100 AMP PANEL TO (N) 200 AMP PANEL License Class — Lic. # �} 3 I U %q _ (SAME LOCATION). INSTALL (N) DESIGNATED CIRCUIT I�BaT l�lL C QLS�,-A Date 2 F _ & Contractor GAS LINE FOR � DUEL OVEN RANGE 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 performance of the work for which this permit is issued. Sq. Ft Floor Area: Valuation: $5000 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 permit is issued. APPLICANT CERTIFICATION 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 sa indemnify and keep harmless the City of Cupertino against liabilities, '�,e costs, and expenses which may accrue against said City in conse nc granting of this permit. Additionally, the applicant understands an with all non -point source regulations per the Cupertino Municipal Code, Section 9.18. % . . / Date 8 ❑ OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for one of 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) I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec.7044, Business & Professions Code). I hereby affirm under penalty of perjury one of the following three 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 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 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 APN Number: 36209001.00 Occupancy Type: PERMIT EXPIRES IF WORK IS NOT STARTED 180 DAYS T ISSUANCE OR 180 D LA LLED INSPECTIO . RE -ROOFS: 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. i Signature o Date: ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER HAZARDOUS MATERIALS DISCLOSURE I have read the hazardous materials requirements under Chapter 6.95 of the California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Section 25532(x) should I store or handle hazardous material. Additionally, should I use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management District I will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Sections 25505, 25533, and 25534. Owner or authorized agent: Date: 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 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, costs, and expenses which may accrue against said City in consequence of the 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. Date Lender's Address ARCHITECT'S DECLARATION 1 understand my plans shall be used as public records. Licensed Professional GENERAL PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 • buildino(E)CuDertino.org m I tit; l �D �OZ0 7 A7EPYiscApp_2011.doc remised 06121111 CITY OF CUPERTINO FEE ESTIMATOR — BUILDING DIVISION NOTE: This estimate does not include fees due to other Departments (Le. 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 (F'ee Resolulion 11-053 Cf. 711113) ADDRESS: 1198 ELMSFORD DR DATE: 08/28/2015 REVIEWED BY: MELISSA Alech. Permit Fee: APN: 362 09 001 BP#: *VALUATION: 1$5,000 xPERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration / Repair PRIMARY SFD or Duplex USE: t'/ec. Insp. 1-ce PENTAMATION 1 REAP2 PERMIT TYPE: WORK UPGRADE E 100 AMP PANEL TON 200 AMP PANEL SAME LOCATION). INSTALL N SCOPE DESIGNATED CIRCUIT & GAS LINE FOR (N) DUEL OVEN RANGE NOTE: This estimate does not include fees due to other Departments (Le. 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 (F'ee Resolulion 11-053 Cf. 711113) Mech. Plan Check Plumb. Plan Check 0.0 hrs $0.00 Elec. Plan Check 0.0 hrs $0.00 Alech. Permit Fee: Plumb. Permit Fee: IPPERMIT Elec. Permit Fee: 1EPERMIT Other Alec/:. Insp. Other Plumb Insp. 0.0 hrs $48.00 Other Elec. Insp. 0.0 hrs $48.00 Aleck. Insp. Fee: Plumh. Insp. t'/ec. Insp. 1-ce NOTE: This estimate does not include fees due to other Departments (Le. 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 (F'ee Resolulion 11-053 Cf. 711113) FEE QTY/FEE MISC ITEMS Plan Check Fee: $0.00 200 amps $48.00 Electrical IBELEC200 Services Suppl. PC Fee: (E) Reg. © OT0.0 1 hrs $0.00 PME Plan Check: $0.00 1� $143.00 Electrical IBREMMISC Special Circuits Permit Fee: $0.00 Suppl. Insp. Fee -.0 Reg. Q OT 0.0 hrs $0.001= # Plumbing $72.00 IPGASRES Piping, Gas <=4 Outlets PME Unit Fee: $0.00 PME Permit Fee: $96.00 Conslruclion Tax: Administrative Fee: ]ADMIN $45.00 O 0 Work Without Permit? ® Yes Q No $0.00 Advanced Planning Fee: $0.00 Select a Non -Residential Building or Structure 0 O i Travel Documentation Fee: ITRA VDOC $48.00 Strong Motion Fee: IBSEISMICR $0.65 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $1.00 SUBTOTALS: T $190.65 $263.00 TOTAL FEE: 1 $453.65 Revised: 07/02/2015