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15080224CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10743 BROOKWELL DR CONTRACTOR: MARA CONSTRUCTION PERMIT NO: 15080224 OWNER'S NAME: NEAL HEMEL 47 LOST VALLEY RD DATE ISSUED: 08/31/2015 OWNER'S PHONE: 4088242429 ORINDA, CA 94563 PHONE NO: (510) 385-8251 ❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL ❑ COMMERCIAL /� ,-/ � � l Z INSTALL TEMP POWER (200 AMP). License Class Lich. #,��v �� ,( qV� Contractor /�GY+1t-/'t n , I ►t-t/Lf to .3dal I hereby affirm that I am licensed under the provisions of C apter 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: $300 performance of the work for which this permit is issued. 3 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: 36921006.00 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 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 - / Issued b Date: granting of this p it. Additionally, the applicant understands and will comply y: - /�1y �'Tf%/�� with all non -p ' t ource regulations•per the Cupertino Municipal Code, Section 9.18. - -- rJ� f RE -ROOFS: Signature Date tl 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 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 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 t pertino Municipal Code, Chapter 9.12 and 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 the Health & Safety Code, Se on 25505, 25533, and 25534. Owner or authorized agen Date. ��Z_Qq_ 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 (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 CUPERTINO GENERAL PERMIT APPLICATION COMMUNITY DEVELOPMiENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 • buildln0(d)CUDertinO.Orq / l/ M IS ❑ PLUMBINCr ❑ MECHANICAL ELECTRICAL ❑ MISCELLAN'EOUS PROTECT ADDRESS APN" ' Y 3 k-� , i / ONERNANIE 'MT -87,4 � -^ _L 7 t']JL� Lli SO STREET ADDRESS /IC ( CITY, STATE, ZIP L FAX CO117.ACT NAJE PHOTS E•?vLAIL STREETADDRESS �/ CITY, STATE, ZIP FAX ElOP'I.'r'i, t 11'TE ORR-BUE3ILDER OWNER AGENT CJ CO'\TRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGD\EEER ❑ DE-VELOPER ❑ TENANT CONTRACTOR I;Al,!&M� O LICENSE NUMBER / � LICENSE TYPE �- BUS. LIC CON,PANY NAME A A F 4X STREET ADDRESS// /y(I L nr f ,� ,/� /f CITY, STATE, ZIP A�� PHO. �4 �SI� ARCHITECTIENGLTEER NAME ^ /V � rJ /� LICENSE NFUMBER U BU . LIC n COMPANY NAME ! v E-MAIL FAY, STREET.ADDRESS CITY, STATE, ZIP PHONE USE OF SFD or DUPLEX ❑ MULTI•F.AI,ffi.Y PROJECT LN WILDL.AND ❑ YES PROTECT IN ❑ YES IS THE BLDG AN ❑ YES BUnANG: COMMERCIAL I URBAN II.'TERFACE AREA Ido FLOOD ZONE NO EICHLER HONE? NO DESCFIPTION OF WORK po TOTAL VALUATION: OQ RECEIiEDB] By my signature below, I certify to each of the following: I am the property owner or authorized agent to act on the property owner's behalf. I have read this application and the information Ihav vided is correct. I have read the Description ofWork and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating t ild - construction. I auth representatives of Cupertino to enter the zbo e-ide i5ed property for inspection purposes. SienatureofApplicant/Agent:Date: -PPLEMENTAL II\'FOR-MATION REQUIRED o cE CSE_OI�L] OYER THE CO U TER St i V ra c; s s C � 3 ?: ❑ T21JDR �• MEPMiscA1PP_2011.doc revised 06121/11 M � CITY OF CUPERTINO FEE ESTIMATOR - BUILDING DIVISION APPLIANCE / EQUIP TYPE ADDRESS: 10743 BROOKWELL DR DATE: 08/31/2015 REVIEWED BY: SEAN UNITS APN: BP#: *VALUATION: $300 PERMIT TYPE: Electrical Permit PLAN CHECK TYPE: Alteration / Addition / Repair PRIMARY SFD or Du lex p Amps PENTAMATION 1 REAP1 USE: Permit T'ee: PERMIT TYPE: WORK INSTALL TEMP POWER 200 AMP). SCOPE PME Unit Fee: APPLIANCE / EQUIP TYPE FEE ID Plumb. Plan Checi, QTY UNITS BP FEES Elec. Permit Fee: IEPERMIT Temporary Power 1ERT<200 Other Elec. Insp. 0.0 hrs $48.00 200 Amps $48 Permit T'ee: Supp/. Insp Fee PME Unit Fee: $48.00 PME Permit Fee: $48.00 C `oustruclion Tax.- ax:Administrative AdministrativeFee: (ADMIN $45.00 Work Without Permit? O Yes O No $0.00 TOTALS: Travel Documentation Fee: ITRA VDOC $48.00 Strong Motion Fee: 1BSEISMICR NOTE: This estimate does not include fees due to other Departments (Le. Planning, Public Works, Hire, Sanitary Sewer district, Schoo[ nie&!-t otn 1 Thoco foot aro hocod nn tho nroliminary infnrmatinn available and are onlv an estimate. Contact the Dept for addh7 info. FEE ITEMS (Fee Resolution 11-053 &a 7/1/13) dlech. Plan Check Plumb. Plan Checi, Elec. Plan Check 0.0 hrs $0.00 i,lech. Permit Fee: I Plumb. Permit f Elec. Permit Fee: IEPERMIT Other i11ech. Insp. Other Plumb /asp.Li Other Elec. Insp. 0.0 hrs $48.00 Alech. hap. l'i'e: Plumb. Insp. Fee: $0.00 NOTE: This estimate does not include fees due to other Departments (Le. Planning, Public Works, Hire, Sanitary Sewer district, Schoo[ nie&!-t otn 1 Thoco foot aro hocod nn tho nroliminary infnrmatinn available and are onlv an estimate. Contact the Dept for addh7 info. FEE ITEMS (Fee Resolution 11-053 &a 7/1/13) FEE QTY/FEE MISC ITEMS Plan[ Check Fee: Supp1. PC Fee PME Plan Check: $0.00 Permit T'ee: Supp/. Insp Fee PME Unit Fee: $48.00 PME Permit Fee: $48.00 C `oustruclion Tax.- ax:Administrative AdministrativeFee: (ADMIN $45.00 Work Without Permit? O Yes O No $0.00 Advancc,d Planning Fees: Travel Documentation Fee: ITRA VDOC $48.00 Strong Motion Fee: 1BSEISMICR $0.50 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $1.00 SUBTOTALS: $190.501 $0.00 TOTAL FEE: 1 $190.50 Revised: 07/02/2015