11090194CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 20977 FAIRWOODS CT
CONTRACTOR: CAMPBELL
PERMIT NO: 11090194
FAMILY ELECTRIC INC
OWNER'S NAME:
TRACY, CA 95377
PHONE NO: (209) 814-3874
❑ LICENSED CONTRACTOR'S DECLARATION
(- C
BUILDING PERMIT INFO: BLDG ELECT rLunls
License Class Lic. #—s , 6
j " "` r
Contractor Date �
MECH RESIDENTIAL COMMERCIAL
I hereby affir th am licensed under the provisions o Chapt r 9
JOB DESCRIPTION: INSTALL ELECTRIC VEHICLE CHARGING STATION IN
(commenc' th Section 7000) of Division 3 of the Business &Professions
GARAGE
Code an rat 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: $1200
performance of the work for which this permit is issued.
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
permit is issued. (►
V
APN Number: 35913115.00
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
to building construction, and hereby authorize representatives of this city to enter
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
upon the above mentioned property for inspection purposes. (We) agree to save
180 DAYS/FROM LAST CALLED INSPECTION.
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
costs, and expenses which may accrue against said Ci tyur consequence of the
qq� J
I
rantin of this ermit. Additional) the applicant and rstands and will com l
g g p y pp comply
Issued b y: � Date
with all non -point unicipal Code, Section
/r
9.18.
Signature Date
RE -ROOFS:
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
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 (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 tire 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
Section 3700 of the Labor Code, for the performance of the work for which this
permit is issued.
�� / t
Owner or authorized agent: _ /
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
C TRUCTION LENDING AGENCP
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
Lender's Address
APPLICANT CERTIFICATION
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
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
ARCHITECT'S DECLARATION
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
F&M-M
CITY OF CUPERTINO
FEE ESTIMATOR - BUILDING DIVISION
lalADDRESS:
20977 fairwood ct.
DATE: 09/28/2011
REVIEWED BY: bobs.
'-'v }r'C; Y'ri :;'rr11C 7t�iffZ:
APN:
BP#:
"VALUATION: 1$1,200
rPERMIT TYPE: Building Permit
PLAN CHECK TYPE: Alteration / Repair
PRIMARY SFD or Duplex
USE:
Suppl. PC Fee: 0 Reg. 0 OT
PENTAMATION 1GENRES
PERMIT TYPE:
WORK
install ev station in gara_q e
SCOPE
NOTE. This estimate does not include fees due to other Depts (i.e. Public Works, Sanitary Sewer District, School District, etc.).
These fees are based on the vreliminary information available and are onlv an estimate. Contact the Dept for addn'l info.
FEE ITEMS (Fee Resohition 11-053 Ejf. 7/1/IIZ
;liE7cif Z3f(?s: E tt.c:
,�fz<<ta1Or h..i (.it/'.C-}4
MISC ITEMS
'-'v }r'C; Y'ri :;'rr11C 7t�iffZ:
FT, •};,£ E'�A'P:
.r� f -td7F r�"r F'
e;��Jitii' iliPi'1t. fiiSF7,
{ Jj1iF'i' P'i ait?(k i3 %.i17.
E3
fjtl;f' i.:!='C:. h1vp,
Suppl. PC Fee: 0 Reg. 0 OT
0.0
NOTE. This estimate does not include fees due to other Depts (i.e. Public Works, Sanitary Sewer District, School District, etc.).
These fees are based on the vreliminary information available and are onlv an estimate. Contact the Dept for addn'l info.
FEE ITEMS (Fee Resohition 11-053 Ejf. 7/1/IIZ
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee:
$0.00
Select a Mise Bldg/Structure
or Element of a Building
Suppl. PC Fee: 0 Reg. 0 OT
0.0
his
$0.00
PME Plan Check:
$0.00
# Alternative Energy System
$100.00 iCHRGm EV Charging Station
Permit Fee:
$0.00
Suppl. Insp. Feer Reg.
0 OT
Fo.0
hrs
$0.00
PME Unit Fee:
$0.00
PME Permit Fee:
$0.00
0
Work Without Permit? Q Yes Q No
$0.00
Advanced Planning Fee.
$0.00
Select a Non -Residential
Building or Structure
0
i
1." .,{ j
Strong Motion Fee:
1BSEISMICR
$0.50
Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC
$1.00
SUBTOTALS: `
$1.50
$100.00
TOTAL FEE: `
$101.50
Revised: 09/02/2011