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15110161")L CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 21696 COLLINGSWORTH ST CONTRACTOR: .GVJ e j� Gj ebb, C PERMIT NO: 15110161 OWNER'S NAME: KENNEY JOSEPH B AND SHEILA R DATE ISSUED: 11/20/2015 OWNER'S PHONE: ` PHONE NO: LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL COMMERCIAL REPLACE 100 AMP MAIN PANEL SAME LOCATION (_ License Classy Lic Contractor SINLI t 1_ Date I�r 1r_'�- I hereby affirm t1 at 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. �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: 35617054.00 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 WORD IS NOT STARTED correct. I agree to comply with all city and county ordinances and state laws relating WITIIIN 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 i P granting of this permit. Additionally, the applicant understands and will comply Issued by: Date: P t Js with all non -point source regulations per the Cupertino Municipal Code, Section RE -ROOFS: 9.18._��,__�.� ` ` `.'.— Date 4° :SignatU14 �, J 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. D 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) 1, 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 Section 3700 of the Labor Code, for the performance of the work for which this the Health & Safety Code, Sections, 25533, and 25534. 4, yf Owner or authorized agenf -. 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 (Sec. 3097, Civ C.) Lender's Name APPLICANT CERTIFICATION Lender's Address 1 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, ARCHITECT'S DECLARATION 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 DEVELOPk/i�ENT DEPARTMENT - BUILDING DIVISION 10300 TORRE AVENUE - CUPERTINO, CA 0501 ^-3255 (408) 777-3228 - FAX (4-,08) 777-3333 - buiIdinO(d-)CUDeri:Ino.Orq n PLUIvmING ❑ MECHANICAL ELECTRICAL IS-Ijo 61 n ME SCELLA?�iEOUS PROEECT ADDRESS 635 I b Ny I (.1 � i a�l OSlaiRNA1J:E P'r�0?\J �� � ��cJ� � -I✓-.Z STREET L.DDP.ESS � j /� G KJ L-Z/�-"C./` `Z✓V�' I- .ATE, ZIP 2-� I F. CO?NTACT) A JE -�7d o L �� PHO;\ QZ I -` E I�LAII STREET a.DDP.ESS�) Z 'r ) ` �L--� 1�� t/I CITY, STA i EE, ZIP I, FAX ❑ OPM❑ OR'N—F-BUP-.DER ❑ OWNERAGEN'T ❑ CONTF.ACTOR ❑ CO1\7-1P,+.CTORAG- T ❑ .4RC:1BCT ❑ `NGi\�E-R ❑ DEVELOPE-R ❑ 1_?�c�'p CONTRACTOR N -A -ba `�r' L DgSE 1 U'MBFR CJ� qc� LICENSE T�'PE _ BUS. LIC 1 C — COIJ,PA1\Y "NA11T �E-NAIL I FAX STREETADDRESS�) , ` / 4A71Z � I CITY, STATE, ZIP PHONF-- 1r ARCHITECT/E ;GN-EHR NAME I LICE>\SE NUMBER I BUS. LIC COMTAXY NAh E I E-1\'Lk . I FAX STREET ADDRESS I CITY, STATE, ZIP PHONE USE OF ❑ SFD or DUPL -, ❑ 1✓,ULTI-TA M Y . PROM:CT LN WILDLAND ❑ Y: -:s PROi-CT IN ❑ YES IS ire BLDG AN ❑ ti =S BULTALNG: ❑ CobcM '.CLAL iJP3 2\ LN'T ERPACE AREA ❑ NO I FLOOD ZOME ❑ ?�-O I I EICHLER HOlfE? ❑ 1.'0 DESCR1PTI0A' OF WORK L TOTALVALUATIO?\r: 11� I RtC�IV�D��r 3 z } '� u` 1 ?x By my signattre below, I certify to each of the following: I am the propefty owner or auhorized agent to act on he propefty owner's 141f. I have read this application and he information I have provide is CU I have read the Description of Work and veru it is accurate. I agree to comp y with all applicable local ordinances zad state lad; s relating to building c ctio >>` ntatives of Cupertino to enter the above-iddentifi- propel for inspection purposes. Si2:natlrre of Applicant/,gent: _~ Date: Sli- PLEMEN T AL D'�_�I ORATION RE UL'ED x.,... ,.., � h SSS �.., , .:::•,w,..r .....:... :, -c �4RG'11' 1�11'EPh!iscApp_2011.doc revised 06/21/11 a :i CITY OF CUPERTINO FEE ESTIMATOR BUILDING DIVISION ADDRESS: 21696 Collingsworth StDATE: 11/20/2015 REVIEWED BY: Phuong APN: 356-17-054 BP#: 'VALUATION: j$1,000 *PERMIT TYPE: Electrical Permit PLAN CHECK TYPE: Alteration / Addition / Repair PRIMARY SFD or Duplex PENTAMATION 1 REAP2 USE: PERMIT TYPE: A WORK Replace 100 amp main panel same location SCOPE llech. llkw ("he ck 11hvn. I M (37CCA: Elec. Plan Check 0.0 hrs $0.00 :1 OeC hJ."OrM I ix: 8""': Elec. Permit Fee: ]EPERMIT Odferf'hw-.b Zr-sp. Other Elec. Insp. hrs 1 $48.00 Afih, 1* so. F' lr'sp. Fee: ee: VOTE. 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 preliminary information available and are only an estimate. Contact tize Deptjor aaan't info. FEE ITEMS (Fee Resolution 11-053 Fff. -7I/132 FEE QTY/FEE MISC ITEMS SuppL PC.Fe�e F PNM Plan Check: $0.00 PME Unit Fee: $48.00 PME Permit Fee: $48.00 F71 Administrative Fee: . JADMIN $45.00 Work Without Permit? 0 Yes No $0.00 Travel Documentation Fee: I TRA VDOC $48.00 Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $1.00 ........ ................. .. . .. . . Vill' .. . ...... ..... .... . ....... .. .. . ... ............. . . ........ . ... . . ..... . . . . .... . .... ..... . ............. . ...... ...... . . . .... . .... .... . .... . .... ....... . . . . . . . . .... . ....... . .... .... .............. . .. .... .. .. ...... ........ . . . .... . .. .... .... . . . . . .... .... . . ...... . ...... . $190. 501 '1000 $19 0.50 Revised: 10/01/2015