11110171 ` CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 6059 BOLLINGER RD CONTRACTOR:ROMANO ELECTRIC PERMIT NO: 11110171
OWNER'S NAME: BRENT&CHIKAKO SAKURAI 2198 LAUREL DR DATE ISSUED: 11/30/2011
O ER'S PHONE: 8185306567 SANTA CLARA,CA 95050 PHONE NO:(409)564-0583
LICENSED CONTRACTOR'S DECLARATION
p ^r,, BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class C ( O Lic.B /111Q W
{{�� x "1301(( MECH r RESIDENTIAL r COMMERCIAL r
Contractof_I'kQ'YY]I't7 �G Date
I hereby alarm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:SERVICE UPGRADE FROM I OOAMP TO 200AMP
(commencing with Section 7000)of Division 3 of the Business&Professions OVERHEAD
Code and that my license is in full force and effect.
1 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.
I have and will maintain Worker's Compensation Insurance,as provided for by
Section 3700 of the Labor Code,for the performance of(he work for which this Sq.Ft Floor Area: Valuation:$3500
permit is issued.
APPLICANT CERTIFICATION AIN Number:37538005.00 Occupancy Type:
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 stale 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 PERMIT EXPIRES IF WORK IS NOT STARTED
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the WITHIN 180 DAYS OF PERMIT ISSUANCE OR
granting of this permit. Additionally,the applicant understands and will comply 180 DAYS FROM LAST CALLED INSPECTION.
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18.
Signature Date ( ( Issued by: Date:
I* OWNER-BUILDER DECLARATION
RE-ROOFS:
1 hereby affirm that I am exempt from the Contractor's License Law for one of All roofs shall be inspected prior to any roofing material berg installed.If a roof is
the following two reasons: installed without first obtaining an inspection,I agree to remove all new materials for
I,as owner of the property,or my employees with wages as their sole compensation, inspection,
will do the work,and the structure is not intended or offered for sale(Sec.7044,
Business&Professions Code) Signature of Applicant: Date:
I,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business&Professions Code). ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
I hereby affirm under penalty of perjury one of the following three
declarations:
I have and will maintain a Certificate of Consent to self-insure for Worker's HAZARDOUS MATERIALS DISCLOSURE
Compensation,as provided for by Section 3700 of the Labor Code,for the I have read the hazardous materials requirements under Chapter 6.95 of the
performance of the work for which this permit is issued. California Health&Safety Code,Sections 25505,25533,and 25534. 1 will maintain
I have and will maintain Worker's Compensation Insurance,as provided for by compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
Section 3700 of the Labor Code,for the performance of the work for which this Safety Code,Section 25532(a)should I store or handle hazardous material.
Additionally,should 1 use equipment or devices which emit hazardous air
permit is issued. contaminants as defined by the Bay Area Air Quality Management District I will
I certify that in the performance of the work for which this permit is issued,l shall maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
not employ any person in any manner so as to become subject to the Worker's Health&Safety Code,Sections 25505,25533,and 25534.
Compensation laws of California. If,after making this certificate of exemption,I
become subject to the Worker's Compensation provisions of the Labor Code,I must Oor authorized egpgt: (I 3
forthwith comply with such provisions or this permit shall be deemed revoked. 0 d 6-r&I Date:CJ
�l1
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 of work's
correct.I agree to comply with all city and county ordinances and state laws relating for which this permit is issued(Sec.3097,Civ C.)
to building construction,and hereby authorize representatives of this city to enter Lender's Name
upon the above mentioned property for inspection purposes.(We)agree to save
indemnify and keep harmless the City of Cupertino against liabilities,judgments, Lender's Address
cggWd expenses which may accrue against said City in consequence of the
MI of this permit.Additionally,the applicant understands and will comply ARCHITECT'S DECLARATION
wn, I of
source regulations per the Cupertino Municipal Code,Section
9.18• 1 understand my plans shall be used as public records.
Signature Date Licensed Professional
• CITY OF CUPERTINO
6 ITEMS OF 6 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 37538005. 00
DATE ISSUED. . . . . . . : 11/30/2011
RECEIPT #. . . . . . . . . : BS000015435
REFERENCE ID # . . . : 11110171
SITE ADDRESS . . . . . : 6059 BOLLINGER RD
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . :
OWNER . . . . . . . . . . . . : BRENT & CHIKAKO SAKURAI
ADDRESS . . . . . . . . . . : 6059 BOLLINGER RD
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
RECEIVED FROM . . . . : ROMANO ELECTRIC
CONTRACTOR . . . . . . . : JASON ROMANO LIC # 32435
COMPANY . . . . . . . . . . : ROMANO ELECTRIC
ADDRESS . . . . . . . . . . : 2198 LAUREL DR
CITY/STATE/ZIP . . . : SANTA CLARA, CA 95050
TELEPHONE . . . . . . . . : (408) 564-0583
• FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
-ADMIN HOURS 1. 00 41.00 0. 00 41.00 0. 00
1BCBSC VALUATION 3, 500 . 00 1.00 0. 00 1 .00 0. 00
1BSEISMICR VALUATION 3, 500. 00 0. 50 0. 00 0.50 0 . 00
1EPERMITFE FLAT RATE 1.00 44 . 00 0 . 00 44 .00 0.00
IERT<200 UNITS 1 .00 44 . 00 0.00 44 . 00 0.00
1TRAVDOC FLAT RATE 1.00 44.00 0. 00 44 .00 0. 00
---------- ---------- ---------- ----------
TOTAL PERMIT 174 .50 0 .00 174 .50 0. 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CHECK 174.50 #1221
---------------
TOTAL RECEIPT 174 .50
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
103 UFER 304 ROUGH ELECTRICAL
505 FINAL ELECTRICAL
•
iltl0171
GENERAL PERMIT APPLICATION �a\1 u' M E P
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVI 1
10300 TORRE AVENUE•CUPERTINO,CA 95014-3255 M '
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(408)777-3228•FAX(408)777-3333•buildin CU ertino.or
• CUPERTINO
PLUMBING MECHANICAL r� EC AL MISCELLANEOUS
PROJECT ADDRESS - O ILS . _ APN N �-7 G_
OWNERNAME J1�JW�O— _ _ / ��` E-MAIL w
STREET ADDRESS CITY, STAm 1. FAX
VIWA
CONTACT NAME PHO EMAIL
-
STREETADDRESS CTTY STATE, IP �`^ FAX
13 OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT CONTRACTOR 11 CONTRACTOR AGENT 11 ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT
CONTRACTOR NAM
E (� LIC PE NUMB LICENS TYf BUS,LICE
COMPANY ME I(-L CC�r E-MAIL ( FAX
STREET DRE55 ,ST TG ZIP V y� PH NE ^O _
ARC HITECT/ENGINEER NAME NIA LICENSE NUMBER BUS.LICN
COMPANY NAME. 1� ff11 E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
FE01 SFDmDUPLEX ❑ MULTI-FAMILY PROJECT IN WILDLAND ❑ Ya5 PROJECTIN ❑Yes ISTHEBLDGAN YES
NG' ❑COMMERCIAL URBAN INTERFACE AREA NO FLOOD ZONE `�NO EICHLER HOME'/ ❑NO
DESCRIPTION OF WORK
TOTAL VALUATION: �— RECEIVED BY:
By my signature below,I certify to each of the following: 1 am the property owner or outhorimd agent to act on the property owner's behalf. 1 have read this
application and the information I have provided is correct. I have read the Description of Work and verify it is accurate. 1 agree to comply with all applicable local
ordinances and state laws rolatitold. g construction. I a rim representatives of Cupertino to enter the above-i entiE property for inspection purposes.
Signature of Applicant/Agent: (39LIPLI Dale: /
SUPPLEMENTAL INFORUXTION REQUIRED OFFICE USE ONLY
❑ OVERRHE-COUNTER
❑ EXPRESS
g ❑ STANDARD
S ❑ LARGE
AOLE ❑ MAJOR
qW
MEPMacApp_M Ldx revised 06/21/11
CITY OF CUPERTINO
FEE ESTIMATOR- BUILDING DIVISION
• ADDRESS: 6059 bollinger ave DATE: 11/30/2011 REVIEWED BY: larry s
APN: BP#: "VALUATION: 1$3,500
*PERMIT TYPE: Electrical Permit PLAN CHECK TYPE: Alteration/Addition/ Repair
PRIMARY SFD or Duplex PENTAMATION 1REAP2
USE: PERMIT TYPE:
WORK service U rade
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Services 1ECT<200 100 Amps $44
TOTALS: $44.00
Me,.h. Plan Check Phnnb. Plan Cheek Elec.Plan Check 0.0 hrs $0.00
;Ltech. Pr.!%nit hire: Pi-,/,.Permit Fee: Elec.Permit Fee: IEPERMIT
• otho ,11.-oh,hap. Other Plunib Lisp. Other Elec. Insp. E hrs $44.00
,IAe h.Insp. Pee: Plu nb.Insp.Pee: Met.Inv). Fee:
NOTE: This estimate does not Include fees due to other Departments(i.e.Planning,Public Works,Fire,Sanitary Sewer District,School
District etc. . These fees are based on the prelindna Information available and are oniv an estimate. Contact the Dept for anion I Infa
FEE ITEMS(Fee Resolution 11-053 Eff 7/U1 U FEE QTY/FEE MISC ITEMS
Plan Check Fac:
Snppl.
PME Plan Check: $0.00
Permit Fee:
Suppl. Lisp 1"ee
PME Unit Fee: $44.00
PME Permit Fee: $44.00
Construction 7'tra
Administrative Fee: (ADMIN $41.00
Work Without Permit? O Yes 0 No $0.00
.4ubance d Planning Fees:
Travel Documentation Fee: ITRA VDOC $44.00
Strong-Motion Fee: IBSEISMICR $0.50 Select an Administrative Item
• Bldg Stds Commission Fee: IBCBSC $1.00
'SUBTOTALSS'. $174.50 $0.001 TOTAL FEE: $174.50
Revised: 10/01/2011