12050128 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS:-=FOOTHILL&280 CONTRACTOR`'•",-r.n`s--XG 3E PEMM IT NO:12050128
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OWNER'S NAl►IE: CALTRANS n,c TE IsSUN n:0snsnolz
OWNER'S PRONE: PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL COMMERCIAL
License ClassQ-7 G 10 Lie.4__ 1 S'-1113 REPLACE 50 AMP BREAKER WITH A 60 AMP BREAKER
Contractor__��i 6-L-r-G_ Date D S—1 S—I
I hereby affirm that Iam licensedunder the provisions ofChapter 9
(commencingwith Section 7000)of Division 3 ofthe Business&Professions
Code and that my license is in full force and effect.
I hereby affirm under penalty of perjury one ofthe following two declarations:
1 have and will maintain a certificate of consentto self-insure for Worker's
Compensation,as provided for by Section 3700 oTthe Labor Code,for the
performance ofthe work for which this permit is issued. Sq.Ft Floor Area: valuation:$100
have and will maintain Worker's Compensation Insurance,as provided for by
Section 3700 of Ihc Labor Code,for the performance ofthe work for w ich thi �pN Number.
permit is issued. Occupancy Type:
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 D YS 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 DAY LAST CALLED INSPEC IO
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City inconsequence of Ihc t
granting ofthis permit. Additionally,the applicant understands and will comply Issued by: Dater
with all non-point source regulations per the Cupertino Municipal Code,Section
,•,C 1 C
RE-ROOFS-
Signal,"
roofing
SignaturDate �}� _+ J All roofs shalt be inspected priorto any roofing material being installed_If a roof is
installed without first obtaining an inspection,1 agree to remove all new materials for
❑ OWNER-BIIILDER DECLARATION inspection.
Signature of Applicant: Datc:
1 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
1,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 ofthe property,am exclusively contracting with licensed contractors to IIAZARDOIIS NIATFRIALS DISCLOSURF.
construct the project(Sec.7041,Business&Professions Code). 1 have read the hazardous materials requirements under Chapter 6.95 of the
California Ilealth&Safety Code,Sections 25505,25533,and 25534. 1 will
I hereby affirm under penalty of perjury one ofthe following three maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
declarations: Health&Safety Code,Section 25532(a)should 1 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 ofthe work for whichthis 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 Ilealth&Safety Code.Sections 25505,2.9533,and 5534.
Section 3700 of Ihc Labor Code,for dee performance ofthe work forwhich this T r
permit is issued.
Owner or authorized agent:
I certify that in the performance ofthe 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 ofCal ifomia, If,altcr making this certificate of exemption,I CONSTRUCTION LENDING AGENCY
become subject to the Worker's Compensation provisions ofthe Labor Code,1 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
(certify that l 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 1RCRITE:CT'S DECLARATION
and keep harmless the City'ofCupertino 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
GENEIRAL-PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT-BUILDING DIVISION MEP
10300 TORRE AVENUE-CUPERTINO.CA 85014-3255
GURBRI'1M0 (408)777-322$ FAX(408)•777-3333 buildine(5r cupertino oramisc
❑PLUMBING OMEMANICAL WELECMICAL MlSaU_AXEOUS
PROJECT ADDRESS ^mac _ Z$pNx
Ow NER NAME MPHONE
T— o�iLIE > MA�
STF.WrADDRESS CTJY,STATF_ZtP
FAX
CONTACT NAME 1
i W 0T � PHONE
�, �277-1117
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s ADpREss zT /A j L+ S2a FAX
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❑:OWNER ❑QWNER-BIRDER ❑OwNIIt AGENT• .CONTRACTOR. ❑CONTRACTOR AGENT ❑ AjtcHn= ❑ENoINEEt EI DEVELOPER ❑TENANT
CONTRACTOR NAA LICENSE NUMMER 9CIL1113
L[CENSE TYPE BUS.LIC#
COMPANY NAME FAX
WAI-r—. Giru.vLr� INC— E- dbstt 7 wAc s_c�uw�;
STREET'ADDRESS S `�_�w Y 65 ivtit zolf
MY.STATE,Z31-Li&jc E A/ PHONE
6`f P ql6-7r7--o��
ARCHITEC IENGINEER.NAME LICENSE NUMAER BUS,LIC M
COMPANY NAME' E-MAQ FAX
STREET ADDRESS CTCV,STATE.ZIP PHONE
USE OF ❑SPM or DUPLEX ❑ MULTI-FAMILY. Pitomcr 1N wBDL4&m ❑YES PROJECT IN ❑YES IS THE BLDG AN ❑YES-
SUIIDINO: MKMCLA.L URBAN WTERFACEAREA NO FLOOD ZONE NO °EICHI.St HOME? NO
DESCRIPTION OF WORK -
L f�rC/ r f M. wTr ti-
TOTAL VALUATION: 010
- RECEIVED BY: .
By my signature below,I certify to each of the fnlIowiag'°I am the property owner or anthorizcd agent to act on the property owner's behalf I have read this
application and the h tmation I have provided is ro=od.bave read the Description of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating to bailding
contraction.ordinances authorize representatives of CupertiDo to cater the above-identified property for inspection puiposcs.
Signattnz ofApplieaut(Ag=z / Dau. 05 �t " 1 Z
L.EMENTAL'INFORMATION REQUIRED
OFFICE USE ONLY
y OYER-THE-COUNTER
6
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y Q 5TANDARD
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❑ LARGE
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MAJOR
MEPMiscApp 1011.doer revised 06111111
CITY OF CUPERTINO
ESTIMATOR-BUILDING DIVISION
ADDRESS: Foothill Express Wy S 280 DATE; 05/11/2012 REVIEWED BY: Sean
APN: BP#: a � S' *VALUATIQN: $100
x PERMIT TYPE: Building Perrriit PLAN CHECK TYPE: Alteration/Addition I Repair
PRIMARY
S MARY Commercial Building PENTAMATION
PERMIT TYPE: 10EAP7
WORK Replace 50 amp breaker with a 60'amp breaker.
SCOPE
Me::h_Plan Che.-k I'Irmrh.t'Irtrr Check Elec.Plan Check 0.0 hrs $0,00
,blrrh.Penni!Fete: t-horrh.Permit Fee: Elec.Permit Fee: IEPERMIT
(lrher Mcch.Imp. Li Other Phrrnh 1nsp, Other Elec.Insp. 0.0 hrs $44.00
.t•l.x•h.Irr.y,_l�;rr Plrenh.hrsp./�c•�: /';lcc,Inap.lac:
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 De t or addn l in o.
FEE ITEMS(Fee Resolution 11-053!i . 7/1/1!,1 FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 Q # Electrical
Suppl. PC Fee: (j) Reg. 0 OT 0.0 hrs $0.00 $0.00 I 1BREMMISC Conductors
PME Plan Check: $0.00
Permit Fee: Hourly Only? Q Yes'Q No $0.00
Suppl. Insp. Fee-.0 Reg. 0 OT d.0 1 hrs $0.00
PME Unit Fee: $0.00
PME Permit Fee: $44.00
C'rmstruction Tax:
Administrative Fee: (ADMIN $41.00 0
Work Without Permit? 0 Yes 0 No $0.00 0
Advanced Planning Fcc: $0.00 1 hours Inspections 0-
Travel Documentation Fee: ITRAYDOC $44.00 $130.00 ISTtN5P Inspection,Hourly
Strong Motion Fee: IBSEISMICO $0.50 Select an Administrative Item
Blda Stds Commission Fee: IBCBSC $9.00
SUBTOTALS: $130.50 $130.00 TOTAL FEE: $260.50
Revised: 04/01!2012