12120070 CITY OF CUPERTIN,O BUILDING PERMIT
BUILDING ADDRESS: 7603HOLLANDERRY PL CONTRA'CTOW AN,KY CONSTRUCTION, PERMIT N0:121,2001,0
INC.
OWNER'S,NAME: GCEN§ K,11vIA 720.1 VIA,LOMAS D`A'TE,ISSUED:01/25/2013
OWNER'S PHONE: 6502538552 .SAN;JOSE;GA,95139 P110NE;N0 (408)234-2673
❑
JOB DESCRIPTION: RESID LICENSED CONTRACTOR'S DECLARATION ENTIAL_� COMMERCIALO
icense Class :- Lic.#_: � �T SINGLE FAMILY DWELLING.FAMILY ROOM ADDITION
.r--�,
Contractor —NA Y1_' -�/'fQ�/oir/tt Date Z "� SQFT)Si^URGRADE.ELECTRICAL SERVICE PANEL FROM
-.
[hereby,affirm.,that,ham licensed,under theproyisi- ns ofChapfer 9 100
(commencing with Section 7000 of DiAsion'3 oftheBusiness,&Professions, AMP TO'200 AMP
Code_;and that;my license is in fpllF;force and^effect.
1 heieby'affirm,uoder'penalty.,of perjury.one of the1ollowhig Wo,declarations:
I have and will maintain a certificate;of consent to self-insurvfor;Worker',s
Compensation;-as piovided for by Section13700 of the Labor Code,forthe,
'performance-of the work,for which this permit is,issued. Sq:,Ft,FloorArea:` Valuation:168000
1 have and will maintain WOrkeCs Compensation Insurance,as proJided,forby '
'Section 3700 of th"e Labor Code,for the performance of ihe'workfor which this
permit;is issued.
APN Number;,36226064.00• ;Occupancy Type-
APPLICANT CERTIFICATION
I.certify'that 1,have;read this'.applicabon,and;state thai theiabove'information is PERMIT"EXPIRES'IF WOR'K.IS.NOT STARTED
correct.Lagreeto comply•with all city�and county ordinances and state Iaws,relating
to-buildi'ng,construction,and�hereby authorize^=representatives;of iliis cityto enter WITHIN 1-8Q_DRMIT ISSUANCE OR
upon the above rncntioned property for inspection purposes (We)'+dgr'ee,4o save, 180 DAYS'' ALLED INSPECTION.
'indemnify:and keep:harnmless,the City ofCupertino.against:habrlities',judgments,
`costs;and expenses which may ace against rd Cityin consequence of the
:g?antingtof this permit. Additio ;theta icanfunders_iands,andwill comply Iss Date: �. 3
with all non-point"source^ ions pe elCupertino_Municipal Code;,Section
RE-ROOFS:
Signature - Date = All roofs shallbe inspected peon-"to ariy roofingmaterial being;insfalled. If+a.roof-is
installed without fiist.obt`aining an,inspection,I agree to,remove all new'materials,for
-- - inspection. - -
❑ OWN R-BUILDERe_DE_CLARATION
Signature of,Applicant: Date:
.1 herehy„affirm that.1 am exempufrom the Contractor's License,Law^for one of
the following twwreasons: ALL ROOF COVER_INGS'TO:BE CLASS"A”OR'BETTE_R
'I,assowner of.the'property,or,my employees with.wages,as;thditsole,compensation,
will do the work,:and,tIie,§tructure is riot intended d offered for`sale:(Sec.7044',
Business&Professions Code)
`I;as owner ofthe property;ain exclusively contractin'g,;with',licensed.contractot§rto HAZA'RDOUSMATERIALS DISCLOSURE
construct the (project Sec!704.4,Business,&Professions;Code.,
project ) 1 have read'the hazardbus inaterials.cequiremeots:under.Chapter,6.95 of the
California Health•&Safety,Code,Seetions'25505,25533,�and 25534.1will
l,hereby affirm under penalty'of perjuryaone ofthe following three maintain coinphAftee4ithahe Cupertino.Municipal Code;Chapter 9.12 and the
declarations: Health.&Safety Code,S'ection;25532(a),should:I.store or handle hazardous
J have+and will maintaur•a Certificate ofConsent=to self-insure.for Worker's material. Additional ly-,shouldl use equipment or;devices which emrthazardous
Compensation,as`prov,ided;for bygSection 3700 of the Labo_r,Code,for the air contaminatitstas defined`by the B'ayArea,Air Qu ty ManagemefiVDistrict I
Performance of'the Work for=Which this';permit is+issued. will maintain.compliance with thelCupert' n' pal:Code,'Chapter9:11and.
Lhave'and'will•maintain Workers Compensation Insurance,as•,provided,for by the Health&Safety Code;Sections:25 33' and 25534. `
Section_3,700 ofthe'LaboFCode,for the',performance of the;woik for'which this
permit is issued. `
Owneror authorized agent:, Date: -�yy
I certify1hat in the,Orformance,:of the work.forwhi'ch'this'permit is issued,I.shall
not-employ any person m'anymannerso.as°to become:subjectt`o the Wo'rker's
Cofrrperisatron.lawsof,Califomia: 'If,aftermaking,this•certificate;ofexemptionj CONSTRUCTION LENDING-AGENCY
become subject to:.the WorkePs Cornpens-ationrprovisions of the,Labor-"Code,I.must I hereby-affirm',that there:i'_s a,construetion'lending„agency fo_r.the perforinanceof
forthwith comply with such'provisions or this permitshall,be,'deemed revoked. work's for which;this;perm,it;is issued(Sec.3097,Civ C:)
Lender's 1NAme
APPLICANT CERTIFICATION 'Len'der's:.,Address
I.,certify that I hav_eread this,,A -lican-t” ,and.s`tate,that'-,the,above`information is
correct.1'agree,_to,compl 4ith all cityandcountyordinances and state'laws relating
to�building,constructron,;and:fiereby authoriie`represenfati3es,of this city to enter_
�upon`the above.mentioned propertyfor'inspection'purposes(.We)�agiee;to,save
ARGHIT ECT'S'DECLARATION
indeinnifyand;keepFiarmlesstheCityof.Cupertino against liabilities,-judgments;
c"osts,and expenses'which,mayaccnic,,againstsaid City,inconsequence ofthe 11 understand:myplans,shall.be^used as public=records,
granting;of ihis'permrt:,Additionally,the applicant'understaifds`and`Will'comply`
`with all'non-,point source regulations,,perthe,Cupertino Municipal Code,Section 'Licensed,Professional
`Signature, .Date,
CITY OF CUPERTINO
M- ADDRESS:.
.EEE:ESTIMATO;R— BUILDING DI:VISION
7603 hollanderry place DATE: 12113/2012 REVIEWEDBY: bobs.
PN: BP#:, J, /�Q��Q *VALUATION: $68,000
•*PERMIT TYPE': Building Permit PLAN CHECK TYPE: .Addition
PRIMARY 2nd Unit? Y,es No. PENTA_MATIOly
SFD or Duplex , 1R3SFDADD
USE OTC. 0 Yes �No P,ERMIT'TYPE:,
woltx sfd 411 s.f. famil.' room addition-u rade electrical service anel.
SCOPE
TYPE'OF.' FLR AREA
OCCUPANCY TY-PE:. _ CONSTR. s.f. PC FEES PC FEE ID BP FEES BY FEE ID
R-3 (Custom) 11=8,111-B,IV,V=B 411 $1,512:00 4ADDPL'CK '$1,230.00 IADDINSP
TOTALS: 41'1 $1�512.00
$1,230.00
l.- .. = �a= A* You,- - a„ fF y .. .,
lYIECH,`H®URLY � Yes � NoPI,UMB;IUUI2LY � YesQNo ELECHIOURI ®', es No
LfeC1i:,I't1ir,("heck I'i%ii;C..F'ic,ri C'i,ecn Elec.;Plan Check 0.0 hrs $0.00,
Phzifih, per,,;;;f"ev. ElecraPermit`Fee: 1EPERAffT
U,hcr:lech..Insp. 01her Plumb hasp; p,. 0:0 hrs $45.00
Other Elec.Ins"'
ELI
NOTE_'This estimate�does'not''indude fees,d-ue to oth-er�Departments,(Le.Planning;.Public,Works,,Fire,SanitdkvSe gr-District;Schoot
,District,eta). These dird& inorination vailable,and areonl' an-estimate Contact he De tor,addn;'hin o.ant , _
FEE ITEMS (Fee,Re"soluf on:ll,=b53cGf 7ZPJ2) FEE QTY/FEE MISC ITEMS,
P1an.Check Fee: $1;512.00 200 amps; Electrical
Suppl.PC Fee: .0:,Reg. .0 OT 0.0 `hrs $0.00 $45.00 1ERT<200 Services.
PME Plan Check: $0.00
Permit Fee: $1,230.0:0
SuppL Insp.Feer,Reg. C) OT O p hrs .$0..00
PME Unit Fee:
PME'Permit Feer $45:00
C;rfizsfi.=i`rc:°lion acre
Administrative Fee �
Work Without.Permit? ® Yes °(j) No
Advanced:.Plain'ing Fee:, LpiLorreR; $53:43 Select a.Non=Residential
Building or Structure
Travel.Documentation Fee,- LTRAV60C $45:00:
Strom Motion*Fee: IBSEISVCR $6.:80 Select an Admin sfrative Item
131dj St'ds Commission F.ee: ,IBCBSC. -$3:00
hl
�
� ,a,r � � suBTOTALs $2,89.5:23 $45.00 T®TA�FEE. $2',940:23
Revised: 10/01_/W2012