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15120086CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 22771 MEDINA LN CONTRACTOR: DUKE ELECTRIC PERMIT NO: 15120086 OWNER'S NAME: VAN BUREN KAREN H AND PAUL B P 0 BOX 111912 DATE ISSUED: 12/09/2015 OWNER'S PHONE: 6505756421 CAMPBELL, CA 95011 PHONE NO: (408) 309-9395 LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL COMMERCIAL DUPLEX (A&B) REPLACE 2 PANELS WITH 1 (N) 200 AMP License Class m (f / 0 Li,.# 0� '7/ 9 PANEL (PER PG&E) *001)Contractor*001)/40—C-I U /�,�� A 1'C- Dat / 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: $6000 lrmance of the work for which this permit is issued. ave and will maintain Worker's Compensation Insurance, as provided for by "ti3700 of the Labor Code, for the performance of the work for which this APN Number: 34230007.00 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 WI HIN 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 save7 ED INSPECTION. indemnify and keep harmless the City of Cupertino against liabilities, judgments, gD costs, and expenses which may accrue against said City in consequence of the J J granting of this permit. Additionally, the applicant understands and will com ssue Date: with all non -points gulations per the Cupertino Municipal Code, Section RE -ROOFS: 9.18. Signature Dateo-, l� 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 (Sce.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 ipertino 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, Seci' ns 505, 25533, and 25534. .1= � 1 Owner or authorized agent p�s 6 -21411 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 CONSTRUCTION LENDING AGENCY Compensation laws of California. If, after malting this certificate of exemption, I 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 pians 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 GENERALPERMIi APPLICATION COMA4UNITY DEVELOPhhENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 9501A-3255 (408) 777-3228 • FAX (4-08) 777-3333 • buildinaQcuDerino.org / S- M 1% ❑ PLUhLLBN,c, ❑ IfiECI-LkNTICAL, / j ELECTRIC:- T ❑ h-aCELLAmTEOUS PROTECT ADDP-SS/ 7 I% s, 1] - ds I A?N f -3 (0 Z OCvTrRNA AB,/�`� / �� I PHONE 650 — -�*2.I E•1J�r�Z STREET: DDR SS I Z 0 � W d0�/%/'�/W �� CITY,�T.A� �/ � Of _ q I FAX CONTACT NAW --1" Li v " Q -/1 I PHO ��iL' STREETA.DD=- S T- CITY,STATE, ZIP FAX 0 ❑ OkA�--', ❑ ORW:--,-BUTiD`.R ❑ OWI.�tAGF.T C01'I?4CTOR ❑ CO\7FR-4,CT0RAG-1�T ❑ .,RC:=CT ❑ :NGL\=:R ❑ D--%tLOP^R ❑ 7EI-Aj\7 CONTRACTORXAJ,C- (l) �'L/t� C I LICENSE'.NU\SER / I LIC=-SETYP= I BUS. LIC' COIJ,P.SY. YN. J t -t -P— / d - ✓t /' C tTJ�TL�N(��Ii ` ram STREET A DDRES fid, �odr1/l Jim CITY, STATE, ZIP A � 501 r( PHONE �mq--3D3q ARCHITECTrNGLk7ZER NAME I LICENSENUIIMER. BUS. LIC COIA2A_t\Y K. k!1,E E -I✓ II I FAX STREET.4DDRESS I CITY, STATE, ZIP I PHONE USE OF DS,-D-.rDIIPL ❑ 1rULTI-FA,,a Y PROJECTLN' WILD.E1.D ❑ Yzs PROj-=CTLN ❑ Y= -s LS r=- BY T)GtN ❑ 7'=s I. BL IIDNG: ❑ COh9 CIAL LIZ3fN R>\'T=R.FACE AREA ❑ NO FLOOD ZOl\- ❑ NO EICI•MFR HOIJ.E? ❑ NO DESCRIPTION OF WORK I n � PI ` , ^� L_ _ OVAe- - c� V'^z /-Co �C "-)--ooi V �/li V0 - o/U Zo TOTAL VAI UAT10 �: fix` ...:.. _..... _ .......n . w�..-...„ .. ..._.. n:».Y;,:,::.'' .,..:._... .90::. By my signatu-e below, I certify to each of the following: I am the grope_: Ly owner or authorized agent to act on th - L owner's behalf. I have rea 's application and he information I have provided is correct. I have read the Description of Work and verify it is accurate. I agree to comply with all applicab t local ordinances and state laws relating tobui ' co truction. I authorize representatives of Cupertino to enter the above -identified property for inspection purposes. Sigmzture ofApplicgnt/Agent:'k Date— TFORvIATION REQULRED OFTSCE{LSEDNLI a�_EW-: r fir.. i �V Mg y'C _ R.X?nll h11'ERARSC,4Dp_2011.doo remised 0 612 1/11 CITY OF CUPERTINO FEE ESTIMATOR — BUILDING DIVISION ADDRESS 22771 MEDINA LN (A&B) 191 DATE,: 12/09/2015 REVIEWED BY: MELISSA APN: 342 30 007 1 1 BP#: *VALUATION: 1$6,000 1*PERMIT TYPE: Electrical Permit PLAN CHECK TYPE: Alteration / Addition / Repair PRIMARY SFD or Duplex USE: PENTAMATION 1 REAP 2 PERMIT TYPE: 14 WORK DUPLEX (A&B) REPLACE 2 PANELS WITH 1,(N) 200 AMP PANEL PER PG&E) SCOPE Pe�"; we A",uwb. 1"', . C'heek Elec. Plan Check 10.0 1 hrs $0.00 Awlech- Permit b"ec, Elec. Permit Fee: ]EPERMIT Other Elec. Insp. LLJ hrs 1 $48.00 PJ EW: TOTE: 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 the Uept.joraaan,iinj FEE ITEMS (f,ee.Resolution .1.1-053.ff. 7/1113) FEE QTY/FEE MISC ITEMS Mtn heck- Fee: PME Plan Check: $0.00 Pe�"; PME Unit Fee: $48.00 PME Permit Fee: $48.00 Administrative Fee: ]ADMIN $45.00 Work Without Permit? C) Yes (j) No $0.00 Travel Documentation Fee: I TRA VDOC $48.00 Strong Motion Fee: IBSEISMICR $0.78 Select an Administrative Item 131da Stds Commission Fee: IBCBSC $1.00 B $190.78 $0.00 TOTAL FEEi-, $190.78 1 Revised: 10/01/2015 CUPERTINO SMOKE / CARBON MONOXIDE ALARMS OWNER CERTIFICATE OF COMPLIANCE COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 • building(c)cupertino.org /Fermtt No. X 1 1 O o R-(, Address -7 {� �� n L # of Alarm Smoke-( 4 C boliM.lnoxide: PERMIT CANNOT BE FINALED AND COMPLETED UNTIL THIS CERTIFICATE HAS BEEN SLGNE,Q AND REI'LEE� �NED TO THE BUILDING DIVISION PURPOSE This affidavit is a self -certification for the installation of all required Smoke and Carbon Monoxide Alarms for compliance with 2013 CRC Section R314, 2013 CBC Sections 420.6 and 907.2.11.2 where no interior access for inspections are required. GENERAL INFORMATION Existing single-family and multi -family dwellings shall be provided with Smoke Alarms and Carbon Monoxide alarms. When the valuation of additions, alterations, or repairs to existing dwelling units exceeds $1000.00, CRC Section R314 and CBC Sections 907.2.11.5 and 420.6 require that Smoke Alarms and/or Carbon Monoxide Alarms be installed in the following locations: AREA SMOKE ALARM CO ALARM Outside of each separate sleeping area in the immediate vicinity of the bedroom(s) X X On every level of a dwelling unit including basements X X Within each sleeping room X Carbon Monoxide alarms are not required in dwellings which do not contain fuel -burning appliances and that do not have an attached garage. Carbon monoxide alarms combined with smoke alarms shall comply with CBC Section 420.6 and shall be approved by the Office of the State Fire Marshal. Power Supply: In dwelling units with no commercial power supply, alarm(s) may be solely battery operated. In existing dwelling units, alarms are permitted to be solely battery operated where repairs or alterations do not result in the removal of wall and ceiling finishes or there is no access by means of attic, basement or crawl space. Refer to CRC Section R314 and CBC Sections 907.2.11.4 and 420.6.2. An electrical permit is required for alarms which must be connected to the building wiring. As owner of the above -referenced property, I hereby certify that the alarm(s) referenced above has/have been installed in accordance with the manufacturer's instructions and in compliance with the California Building and California Residential Codes. The alarms have been tested and are operational, as of the date signed below. i have read and aclree to comply with the terms and conditions of this statement I sp" C. �DUr ........... V"&I�u ........................................ 49, Eonffacbor Name: J U kZ Vv V 2 hIZ]2=�� 1So.......... LIC4.................................... Date:........ ,....... . V Smoke and CO form. doc remised 03118114