11090057 CITY OF CUPERTIIIO BLILDING PERMIT
BUILDING ADDRESS: 1128 DERBYSHIRE DR CONTRACTOR:WILLOW GLEN PERMIT NO: 11090057
ELECTRIC INC
OWNER'S NAME:
SAN JOSE,CA 95125 PHONE NO:(408)289-9725
LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL❑ COMMERCIALD
License Class G_
p1 SERVICE PANEL UPGRADE 200 AMP
� // j Lie.# � / 1 �O
Contractor wl Ile V,/ b- leo `if k)<- Date C1[7/i/
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
performance of the work for which this permit is issued. Sq.Ft Floor Area: Valuation:$2850
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:36221033.00 Occupancy Type:
permit is issued.
APPLICANT CERTIFICATION '4111,
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 1A0 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 DAY F OM LAST CALLED INSPE IO
indemnify and keep harmless the City of Cupertino against liabilities,judgments, w
costs,and expenses which may accrue against said City in consequence of the -/Ah•
granting of this permit. Additionally,the applicant understands and will comply Issued by: i L Date:
with Cupertino Municipal Code,Section
9.18.
/ RE-ROOFS:
Signatur Date `? A 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
I hereby affirm that I am exempt from the Contractor's License Law for one of Signature of Applicant: Date:
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)
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. 1 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 the Health&Safety Code,Sections 25505,25533,and 25534.
Section 3700 of the Labor Code,for the performance of the work for which this /,/
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
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
-demnify and keep harmless the City of Cupertino against liabilities,judgments,
s,and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records.
nting 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
CITY OF CUPERTINO
FEE ESTIMATOR-BUILDING DIVISION
ADDRESS: 1128 derbyshire dr. DATE: 09/07/2011 REVIEWED BY: bobs.
APN: BP#: "VALUATION: $2,850 —,
PPEMIT TYPE: Electrical Permit PLAN CHECK TYPE: Alteration /Addition / Repair
ARY TP—EnA74T—ATION 1 REAP2
USE: SFD or Duplex PEIT YPE:
WORK service upgrade to 200am s.
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Services 1 ERT<200 100 Amps $44
TOTALS: L $44.00
Elec.Plan Check 0.0 hrs $0.00
Elec.Permit Fee: IEPERMIT
Other Elec.Insp. 0.0 hrs $44.00
.-J L
NOTE: This estimate does not include fees due to other Depts(i.e.Public Works,Sanitary Sewer District,School District,etc.).
Thesefees are based on the preliminary in ormation available and are onl an estimate. Contact the De t or addh 7 info,
FEE ITEMS (Fee Resolution 11-053 EIL 7`1,%11) FEE QTY/FEE MISC ITEMS
PME Plan Check: $0.00
'---F--=
PME Unit Fee: $44.00
PME Permit Fee: $44.00
Administrative Fee: ]ADMIN $41.00
Work Without Permit? Q Yes (2) No $0.00
Travel Documentation Fee: ITRA VDOC $44.00 i
Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item
131dLyStds Commission Fee: 1BCBSC $1.00
SUBTOTALS: $174.50 $0.00 TOTAL FEE: $174.50
Revised: 09/02/2011