B-2016-1189CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS:
CONTRACTOR:
PERMIT NO: B-2016-1189
10395 1UDYAVE CUPERTINO, CA95014-3524 (375 08 053)
OWNER/BUILDER
OWNER'S NAME:
DATE ISSUED: 01/14/2016
OWNER'S PHONE:
PHONE NO:
LICENSED CONTRACTOR'S DECLARATION
BUILDING PERMIT INFO:
License Class Lic. #
Contractor OWNER/BUILDER Date
X BLDG X ELECT _ PLUMB
MECH X RESIDENTIAL COMMERCIAL
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.
JOB DESCRIPTION:
REPLACE (E) ELECTRICAL PANEL WITH A (I) 200 AMP PANEL,
I hereby affirm under penalty of perjury one of the following two declarations:
SAME LOCATION
1. 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
performance of the work for which this permit is issued.
2. 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
Sq. Ft Floor Area:
Valuation: $3500.00
this permit is issued.
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above
Number:
Occupancy Type:
information is correct. I agree to comply with all city and county
375 08 053
3 75
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, costs, and
PERMIT EXPIRES IF WORK IS NOT STARTED
expenses which may accrue against said City in consequence of the
S PERMIT ISSUANCE OR
granting of this permit. Additionally, the applicant understands and will
comply with all non-point source regulations per the Cupertino Municipal
aWITHIN
OWNER-BUILDER DECLARATION
RE-ROOFS:
I hereby affirm that I am exempt from the Contractor's License Law for one of the
All roofs shall be inspected prior to any roofing material being installed. If a roof is
following two reasons:
installed without first obtaining an inspection, I agree to remove all new materials for
1. I, as owner of the property, or my employees with wages as their sole
inspection.
compensation, will do the work, and the structure is not intended or offered
for sale (Sec.7044, Business & Professions Code)
Signature of Applicant:
0.2. 0, as owner of the property, am exclusively contracting with licensed
Date:
contractors to construct the project (Sec.7044, Business & Professions Code).
I hereby affirm under penalty of perjury one of the following three declarations:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
1. 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
HAZARDOUS MATERIALS DISCLOSURE
performance of the work for which this permit is issued.
I have read the hazardous materials requirements under Chapter 6.95 of the
2. I have and will maintain Worker's Compensation Insurance, as provided for
California Health & Safety Code, Sections 25505, 25533, and 25534. I will
by Section 3700 of the Labor Code, for the performance of the work for which
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
this permit is issued.
Health & Safety Code, Section 25532(a) should I store or handle hazardous
mortify that in the performance of the work for which this permit is issued, I
material. Additionally, should I use equipment or devices which emit hazardous
Air Management District I
�
air contaminants as defined by the Bay Area Quality
VV shall not employ any person in any manner so as to become subject to the
will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and
Worker's Compensation laws of California. If, after making this certificate of
the Health & Safety Code, Sections 25505, 25533, and 25534.
exemption, I become subject to the Worker's Compensation provisions of the
Labor Code, I must forthwith comply with such provisions or this permit shall
Owner or authorized '
be deemed revoked.
Date—/Z/—/ (o
APPLICANT CERTIFICATION
CONSTRUCTION LENDING AGENCY
I certify that I have read this application and state that the above information is
I hereby affirm that there is a construction lending agency for the performance
correct. I agree to comply with all city and county ordinances and state laws
of work's for which this permit is issued (Sec. 3097, Civ C.)
relating to building construction, and hereby authorize representatives of this city
Lender's Name
to enter upon the above mentioned property for inspection purposes. (We) agree
to save indemnify and keep harmless the City of Cupertino against liabilities,
Lender's Address
judgments, costs, and expenses which may accrue against said City in
consequence of the granting of this permit. Additionally, the applicant
ARCHITECT'S DECLARATION
understands and will comply with all non-point source regulations per the
I understand my plans shall be used as public records.
Cupertino MunicipayCodd , Section 9.18.
Licensed
Signature' `!
Professional
�. CITY OF CUPERTINO
- FFF FNTIMATOR — BUILDING DIVISION
191 ADDRESS: 10295 JUDY AVE
DATE: 01/14/2016
REVIEWED BY: MELISSA
APN:
BP#:
*VALUATION: 1$3,500
*PERMIT TYPE: Electrical Permit
PLAN CHECK TYPE: Alteration / Addition / Repair
PRIMARY
or Duplex
USE:
PENTAMATION
PSFD
PERMIT TYPE: 1 REAP
WORK
REPLACE E ELECTRICAL PANEL WITH A N 200 AMP PANEL SAME LOCATION
SCOPE
1(3erinir Fee:
APPLIANCE / EQUIP TYPE
FEE ID
QTY/FEE
QTY
UNITS
BP FEES
Services
1 ERT<200
200
Amps
$48
TOTALS:
$48.00 I I
COTE: 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 preliminary information available and are only an estimate. Contact the Dept.tor addn7 into.
FEE ITEMS . TEMS (Fee Resolution 11-053 E 711113)
FEE'
QTY/FEE
MISC ITEMS
Plam /1e.ck 1-
S-uppL.PCP-,`ee
PME Plan Check:
$0.00
1(3erinir Fee:
.fie.%
PME Unit Fee:
$48.00
PME Permit Fee:
$48.00
(,"O� �'i�'iieciion d ax
Administrative Fee: IADMIN
$45.00
Without Permit? 0 Yes 0 No
$0.00
,¢Work
,.rl;j%ii'F�c.'?LFSZIZPr«t;c;,.
Travel Documentation Fee: ITRAVDOC
$48.00
Strong 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: 01/01/2016