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15060065 (2),1 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 7457 ROLLINGDELL DR CONTRACTOR'1} PERMIT NO: 15060065 OWNER'S NAME: LEE TERRY G AND RONA H DATE ISSUED: 06/09/2015 OWNER'S PHONE: 5102077479 PHONE NO: LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL COMMERCIAL /] REPLACE (E) 100AMP PANEL WITH (N) 100AMP PANEL, License Class o Lic. # SAME LOCATION e6`t Contractor )-'\ DateMt 5 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: Valuation: $1000 erformance of the work for which this permit is issued. 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: 35932008.00 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 NOT STARTED correct. I agree to comply with all city and county ordinances and state laws relating WITHIN 18 OF T 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 PAYS FR ST 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 / granting of this permit. dd' ionally, the applicant understands and will compl s y: with all non -point source a lations per the Cupertino Municipal ' de, Section 9.18. ,,, RE -ROOFS: Signature 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 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(x) 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 Cupertinf Municipal Code, Chapter 9.12 and I have and will maintain Worker's Compensation Insurance, as provided for by the Health & Safety Code, Sections 25505, 3, and 25 _4. Section 3700 of the Labor Code, for the performance of the work for which this Owner or authorized agent: Da`t5 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 DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 • buildinq(a.cupertino.org 1,5`0 61 `�j 1bu ❑ PLUMBING ❑ MECHANICAL QSr ECTRICAL []MISCELLANEOUS PROJECT ADDRESS L I P G C/ %�F? APN f Z r v PHONE�� OWNER NAME�, D r ��i (rte- /',i E-MAIL STREET ADDRESS a CITY, STATE, ZIP FAX CONTACT NAME I � PHONE STREET ADDRESS CITY, STATE, ZIP / FAX ❑ OWNER ❑ OWNiER-BUILDER ❑ OWNER AGENT l.J COA*I'RACTOR ❑ CONTIRACTORAGENT ❑ ARCHITECT ❑ ENGINEER ' ❑ DEVELOPER ❑ TENANIT CONTRACTOR NAME q ` vl ! / LiY✓ 1. °r �n LICENSE NUMBER O�D D LICEDISE TYPE I�� l C> BUS. LIC COMPADIY NAME E-MAIL FAX STREET ADDRESS / ( (ap � CITY, STATE, � �� [.✓"�a �l �/d- PH NE •,�l(i �/'(rte/�-�� U ARCMTECT/ENGITEER NAME LIC EDdSE NUMBER BUS. LIC # COMPANY NAME E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHOATE USE OF SFD . DUPLEX ❑ MULTI -FAMILY B=LNIIG: ❑ COMMERCIAL PROTECT IN WILDLAND ❑ YES URBAN ]M=ACE AREA ❑ NO PROJECT IN FLOOD ZONE ❑ YES ❑ NO IS THE BLDG AN ❑ YES EICHLER HOME? ❑ NO DESCRIPTION OF WORK c.t-e— TOTAL VALUATIODI: J C.� • (i ` ;. M'�' v By may signature below, I certify to each Iffirfollowing: I am the property owner or authorzed agent to act on the property owner's be ave read this application and the information I have prorrect. I have read the Description of Work and verify it is accurate. gree y with all applicable local ordinances and state laws relating to builuction. I authorize representatives of Cupertino to enter the abo e -i property for inspection purposes. Signature of Applicant/Agent: Date: 6 SUPPLE NTAL INFORMATION REQUIRED �� or�•icE I�sEbz,�k�'�,,�„,�� ,, ; �OVERTHE COUAI R��. W n i s MEPMiscApp_2011.doc revised 06/21/11 CITY OF CUPERTINO rM-7-1 FEE ESTIMATOR —BUILDING DIVISION APPLIANCE / EQUIP TYPE ADDRESS: 7457 ROLLINGDELL DR DATE: 06/09/2015 REVIEWED BY: MELISSA UNITS APN: 359 32 008 BP#: *VALUATION: j$1,000 *PERMIT TYPE: Electrical Permit PLAN CHECK TYPE: Alteration / Addition / Repair PRIMARY SFD or Duplex USE: Amps PENTAMATION 1 REAP PERMIT TYPE: A ORK F REPLACE E 100AMP PANEL WITH N 100AMP PANEL SAME LOCATION OPE Suppl, Insp T'ee APPLIANCE / EQUIP TYPE FEE ID Plumb. Plan (heck QTY UNITS BP FEES Elec. Permit Fee: IEPERMIT Services 1 ERT<200 Other Elec. Insp. 0.0 hrs $48.00 100 Amps $48 Permit Fee: Suppl, Insp T'ee PME Unit Fee: $48.00 PME Permit Fee: $48.00 Construction ?ax: Administrative Fee: ]ADMIN $45.00 Work Without Permit? 0 Yes ) No $0.00 TOTALS:" A Travel Documentation Fee: ITRAVDOC $48.00 Stroniz Motion Fee: IBSEISMICR 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 nreliminary information available and are only an estimate. Contact the Dent for addn'1 info. FEE ITEMS (Fee Resolution 11-053 Eff. 7/1/13) ;L1ech. Plart Check Plumb. Plan (heck Elec. Plan Check 0.0 hrs `$0.00 tLlech. Permit bee: Plumh. Permit Fee: Elec. Permit Fee: IEPERMIT Other.:Uech Imp. Other Plumb Insp.Lj Other Elec. Insp. 0.0 hrs $48.00 Adech. Insp. Fee: Phrnrb. leap. Fee: Elec. Imp. Fee: 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 nreliminary information available and are only an estimate. Contact the Dent for addn'1 info. FEE ITEMS (Fee Resolution 11-053 Eff. 7/1/13) FEE QTY/FEE. MISC ITEMS Plan Check Fee: S'uppl..I'C.' T ee PME Plan Check: $0.00 Permit Fee: Suppl, Insp T'ee PME Unit Fee: $48.00 PME Permit Fee: $48.00 Construction ?ax: Administrative Fee: ]ADMIN $45.00 Work Without Permit? 0 Yes ) No $0.00 Advanced Planning Tees: A Travel Documentation Fee: ITRAVDOC $48.00 Stroniz Motion Fee: IBSEISMICR $0.50 Select an Administrative Item Bldg, Stds Commission Fee: IBCBSC $1.00 SUBTOTALS,:, $190.50 $0.00 TOTAL FEE:-. $190.50 Revised: 05/07/2015