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11040226 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 6367 BLACKWOOD DR CONTRACTOR:JOHNSTON ELECTRICAL PERMIT NO: 11040226 CONTRACTOR OWNER'S NAME: MARGARET KELM 1302 LINCOLN AVE STE 204 DATE ISSUED:04/29/2011 OWNER'S PHONE: 4082571239 SAN JOSE,CA 95125 PHONE NO:(408)266-0236 LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL ❑ COMMERCIAL ❑ / ELECTRICAL PANEL UPGRADE TO 200 AMP. License Class �� D Lic.# tF/ Contractor SbANkr 5�c 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. Sq.Ft Floor Area: Valuation:$1700 I hereby affirm under penalty of perjury one of the following two declarations: 1. I have and will maintain a certificate of consent to self-insure for Worker's APN Number:36918003.00 Occupancy Type: Compensation,as provided for by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. 2. 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 foPERMIT EXPIRES IF WORK IS NOT STARTED r wh is permit is issued. WITHIN 180 DAYS OF PERMIT ISSUANCE OR APPLICANT CERTIFICATION 180 DAYS FROM LAST CALLED INSPECTION. 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 Issued by: ^—` Date: upon the above mentioned property for inspection purposes. (We)agree to save indemnify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City in consequence of the granting of this permit. d 'tionally,the applicant understands and ill co ply with RE-ROOFS: all non-point source re I on er the Cupert' o Municipal Code, ectio 9.18. All roofs shall be inspected prior to any roofing material being installed.If a roof is 7 n installed without first obtaining an inspection,I agree to remove all new materials for Signature Date C� / inspection. Signature of Applicant: Date: ❑ OWNER-BUILDER DECLARATION ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: 1. 1,as owner of the property,or my employees with wages as their sole HAZARDOUS MATERIALS DISCLOSURE compensation,will do the work,and the structure is not intended or offered for I have read the hazardous materials requirements under Chapter 6.95 of the sale(Sec.7044,Business&Professions Code) California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain 2. I,as owner of the property,am exclusively contracting with licensed contractors to compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health& construct the project(Sec.7044,Business&Professions Code). Safety Code,Section 25532(a)should I store or handle hazardous material. Additionally,should I use equipment or devices which emit hazardous air I hereby affirm under penalty of perjury one of the following three declarations: contaminants as defined by the Bay Area Air Quality Management District I will i. I have and will maintain a Certificate of Consent to self-insure for Worker's maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the Compensation,as provided for by Section 3700 of the Labor Code,for the Health&Safety Code,Sections 25505,25533,and 2 534. performance of the work for which this permit is issued. bOwn, or iz ent: 2. I have and will maintain Worker's Compensation Insurance,as provided for by Date: `T Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. CONSTRUCTION LENDING AGENCY 3 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 I hereby affirm that there is a construction lending agency for the performance of work's Compensation laws of California. If,after making this certificate of exemption,I for which this permit is issued(Sec.3097,Civ C.) become subject to the Worker's Compensation provisions of the Labor Code,I Lender's Name must forthwith comply with such provisions or this permit shall be deemed Lender's Address revoked. ARCHITECT'S DECLARATION APPLICANT CERTIFICATION I understand my plans shall be used as public records. 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 Licensed Professional 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, costs,and expenses which may accrue against said City in consequence of the granting of this permit.Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. Signature Date CITY OF CUPERTINO 5 ITEMS OF 5 PERMIT RECEIPT OPERATOR: suew COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN . . . . . . . . : 36918003 . 00 DATE ISSUED. . . . . . . : 04/29/2011 RECEIPT 4. . . . . . . . . : BS000013338 REFERENCE ID # . . . : 11040226 SITE ADDRESS . . . . . : 6367 BLACKWOOD DR SUBDIVISION . . . . . . CITY . . . . . . . . . . . . . . CUPERTINO IMPACT AREA . . . . . . OWNER . . . . . . . . . . . . : MARGARET KELM ADDRESS 6367 BLACKWOOD DR CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM . . . . : JOHNSTON ELECTRICAL CONTRACTOR . . . . . . . : BRIAN JOHNSTON LIC # 23411 COMPANY . . . . . . . . . . : JOHNSTON ELECTRICAL CONTRACTOR ADDRESS . . . . . . . . . . : 1302 LINCOLN AVE STE 204 CITY/STATE/ZIP . . . : SAN JOSE, CA 95125 TELEPHONE . . . . . . . . : (408) 266-0236 FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- ---------- 1BCBSC VALUATION 1, 700 .00 1. 00 0 .00 1 . 00 0 . 00 1BELEC200 METERS 1. 00 42 . 00 0 . 00 42 . 00 0. 00 1BSEISMICR VALUATION 1, 700 . 00 0 . 50 0 . 00 0 .50 0. 00 1EPERMITFE FLAT RATE 1 . 00 42 . 00 0 . 00 42 . 00 0. 00 1TRAVDOC FLAT RATE 1 . 00 42 . 00 0 . 00 42 . 00 0. 00 ---------- ---------- ---------- ---------- TOTAL PERMIT 127.50 0 .00 127 .50 0 . 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CHECK 127 . 50 2456 --------------- TOTAL RECEIPT 127.50 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 103 UFER 304 ROUGH ELECTRICAL 505 FINAL ELECTRICAL Building Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014-3255 Telephone: 408-777-3228 C U P E RT I N O Fax: 408-777-3333 CONTRACTOR/ SUBCONTRACTOR LIST JOB ADDRESS: PERMIT# , 9)`7--1- OWNER'S NAME: _ LVV� PHONE# S 7 r"L-3 GENERAL CONTRACTOR: p BUSINESS LICENSE# 00 ADDRESS: �?LAC )zV CITY/ZIPCODE: *Our municipal code requires all businesses working in the city to have a City of Cupertino business license. NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE GENERAL CONTRACTOR AND ALL SUBCOYNTRACTORS HAVE OBTAINED A CITY O CUP RTINO BUSINESS LICENSE. I am not using any subcontractors: 'gnature Date Please check applicable subcontractors and complete the following information: V SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets & Millwork Cement Finishing Electrical Excavation Fencing Flooring/ Carpeting Linoleum / Wood Glass / Glazing Heating Insulation Landscaping Lathing Masonry Painting/Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile Owner/Contractor Signature Date CITY OF CUPERTINO FEE ESTIMATOR-BUILDING DIVISION ADDRESS: 6367 blackwood dr. DATE: 04/29/2011 REVIEWED BY: bobs. APN: BP#: "VALUATION: 1$1,700 r PERMIT TYPE: Electrical Permit PLAN CHECK TYPE: Alteration /Addition/ Repair PRIMARY SFD or Duplex lex PENTAMATION 1 REAP2 USE: PERMIT TYPE: 19 WORK service upgrade to 200 amps. SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Services 1 ERT<200 100 Amps $42 TOTALS: $42.00 Elec.Plan Check 0.0 1 hrs $0.00 Elec.Permit Fee: IEPERMIT Lj -L-- Other Elea Insp. 0.0hrs $42.00 NOTE. These ees are based on the preliminary information available and are only an estimate. Contact the Dept-for addh 7 info. FEE ITEMS (hie Resolution 09-051 F:ff 7/1;10) FEE QTY/FEE MISC ITEMS PME Plan Check: $0.00 PME Unit Fee: $42.00 PME Permit Fee: $42.00 Work Without Permit? 0 Yes No $0.00 Travel Documentation Fee: ITRA VDOC $42.00 Stron. Motion Fee: IBSEISMICR $0.50 Select an Administrative Item Bldg) Stds Commission Fee: IBCBSC $1.00 SUBTOTALS: 1 $127.50 $0.00 TOTAL FEE: 1 $127.50 Revised: 04/29/2011 GENERAL PERMIT APPLICATION SEP COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION E 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 (408)777-3228 •FAX (408)777-3333• MISC CUPERTINO PLUMBING MECHANICAL CTRICAL MISCELLANTEOUS PROTECT ADDRESS b I a�I ` ,`� r AP v �� / /�� Dr OWNER NAME (ro JMO)7,�;--7-10M E-MAIL STREET ADDRESS /,; �/ CITY, A IP / - /��^�I FAX CONTACT NAME U PHONE {V�Y V�E---NIAIIlL STREET ADDRESS CITY,STATE,ZIP FAX ❑ OWNER-BUILDER ❑ OWNER AGENT CON"I"RACTOR ❑CON fRACCOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT CONT1 NAME `G�� LICE,' E T'MBF � 7L[CEvS Yib BUS. 73111 COMPANY NAME E-TviA1L F/��0� /1/�/� � I I O '��f(� n(�(/,Q(lt' �(f(/J/ S _SS e, O CI ATEI LZ b.7� `j1 - �I �l� /�/JlL -U ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC# �+ COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE USE OF ❑ SFD or Duplex ❑ Multi-Family PROJECT IN VIILDLAND PROJECT IN STRUCTURE: ❑ Commercial URBAN INTERFACE AREA ❑ Yes ❑ No FLOOD ZONE ❑ Yes ❑ No DESCRIPTION OF WORK c TOTALV"ALUATION: �`} RECEIVED BY: By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on the property owner's behalf. I have read this application and the information I have provided is rrect. I have read the Description of Work and verify it is accurate. I a e to ply with all applicable local ordinances and state laws relating fo it c s ction�41 thorize representatives of Cupertino to enter the above-idem red pro/ for inspection purposes. Signature of Applicant/Agent: Date: {' SUPPLEMENTAL INFORMATION REQUIRED O,r10E USE ONLY w OYER THE-COUNTER a r ❑ EXPRESS U x ❑ STANDARD U dZ ❑ LARGE a ❑ MAJOR WPMiscApp_201 1.doc revised 03/16111