15050014 (2) CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 22080 WALLACE DR _ CONTRA_CTO 1 a'i A_V�ePERMIT NO: 15050014
-A
OWNER'S NAME: ZAMIR ITAMAR AND SHIRY DATE ISSUED:05/04/2015
OWNER'S PHONE: 6508611012 PHONE NO:
LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL COMMERCIAL
INSTALL TEMPORARY POWER
License Class gn Lic.# d
Contractor Det` e,, p x� `a 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
pr=f1ceiof the work for which this permit is issued. Sq.Ft Floor Area: Valuation:$275
wll 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:32603039 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 FRO l 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 Date: J [ �l/
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.
RE-ROOFS:
Signature Date 5415, All roofs shall be inspected r►or 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. .1 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 25505,25533,#25534.
Section 3700 of the Labor Code,for the performance of the work for which this7 .
Owner or authorized agent: J I
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
� v
GENERAL PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 V
�� (408)777-3228 FAX (408)777-3333• buifdingcupertino.orq RTINO ` vMISIC
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❑PLUMBING ❑MECHANICAL E ZELECTRICAL [:]MISCELLANEOUS
PROJECT ADDRESS .,ij 2 O • t Aee Y APN# 1O f / A 2
OWNERNAME L V J A PHONE b E-MAIL — V
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STREET ADDRESS CITY, STATE,ZIP FAX
CONTACT NAME , E� PHONE HOg-,�c7'gc'/Ll? E-MAIL O�q� Ya �.co,
STREET ADDRESS `I CITY,STATE, ZIP q5t) 1 FAX
Vp I D '-Lo°I S Los U a+-o s CA
❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT UG CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAMEC�AYN�Q� �AYZCkN� LICENSE NUMBERLl I() S LICENSE TYPE: BUS.LIC#
COMP Y NAME E-MAIL -1FAX
Ayge e CCN/1 kACti �SHorvl iaZ�a a.1.5cU, �c,w� L)t3,S -7 -7
STREET ADDRESS,FQ n �x CITY,SL A'S �
IP C7 PHONE u -2��
ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC#
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF ❑SFD or DUPLEX ❑ MULTI-FAMILY PW ILDLAND ❑ YES PROJECT IN ❑YES IS THE BLDG AN ❑YES
BUILDING: ❑COMMERCIAL FURZBAN71NTERFACE AREA ❑ NO FLOOD ZONE ❑NO EICHLER HOME? ❑ NO
DESCRIPTION OF WORK ]
+ZD "�C -
TOTAL VALUATION: 31� RECEIV
By my signature below,I certify to each of the following: I am the property owner ora r'med agent to act on the prrty owner's b have read this
application and the information I have provided is correct. I have read the Descriptio of Work and verify it is accur comply with all applicable local
ordinances and state laws relating to building construction. I authorize rep esentatives of Cupertino to enter the above-identified property for inspection purposes.
Signature of Applicant/Agent: Date: g I i U f I S
SUPPLEMENTA INF TION REQUIRED OFFICE USE ONLY
w ❑ OVER-THE=COUNTER
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0,EXPRESS 'f
❑ STANDARD
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a ❑' LARGE
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�13 MAYOR '
MEPMiscApp_201 1.doc revised 06/21/11
CITY OF CUPERTINO
FEE ESTIMATOR-BUILDING DIVISION
ADDRESS: 22080 WALLACE DR DATE: 05/04/2015 REVIEWED BY: MELISSA
APN: 326 03 039 BP#: *VALUATION: $275
*PERMIT TYPE: Electrical Permit PLAN CHECK TYPE: Alteration/Addition/ Repair
PRIMARY PENTAMATION 1 REAP14
USE: SFD or Duplex PERMIT TYPE:
WORK INSTALL TEMPORARY POWER
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Temporary Power 1ERT<200 100 Amps $48
TOTALS: $48.00
Afech. Plan Check Plumb.Plan(:'heel- Elec.Plan Check 0.0 hrs $0.00
�blech. Permit fee: Plumb. Permit Fee: Elec.Permit Fee: 1EPERMIT
—L--Other Alech. Insp. Other Plumb Insp. Other Elec.Insp. 0.0 hrs $48.00
ztlech.hasp. 1+'ee: Plumb. hasp. tee:
Elec.Insp.Fee:
NOTE:This estimate does not include fees due to other Departments(Le.Planning,Public Works,Fire,Sanitary Sewer District,School
District,eta). These fees are based on the prelimina information available and are only an estimate. Contact the Dept for addn'1 info.
FEE ITEMS (Fee Resolution 11-053 Eff. 7/1/131 FEE QTY/FEE MISC ITEMS
Plan Check lee:
Suppl. PC Fee
PME Plan Check: $0.00
Permit Fee:
Suppl. Ins p Fee
PME Unit Fee: $48.00
PME Permit Fee: $48.00
Construction Tax:
Administrative Fee: ]ADMIN $45.00
Work Without Permit? 0 Yes 0 No $0.00
Advanced Planning lees:
Travel Documentation Fee: ITRAVDOC $48.00
Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item
Bldg Stds Commission Fee. IBCBSC $1.00
Lr SUBTOTALS: $190.50 $0.00 �TOTAL FSE: $190.50
Revised: 04/01/2015