14020017 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10465 DEMPSTER AVE CONTRACTOR:VINCE MOFFITT PERMIT NO: 14020017
CONSTRUCTION
OWNER'S NAME: PROKEY NORMAN T AND BETTY L 379 GHUREHILL PL DATE ISSUED:02/04/2014
OWNER'S PHONE: 4086851417 GILROY,CA 95020 PHONE NO:(408)427-1417
❑ LICENSED CONTRACTOR'S DECLCARATION JOB DESCRIPTION: RESIDENTIAL El COMMERCIALE]
License Class' l Lic.# S� PANEL UPGRADE 200 AMP
Contractor �J l A)C C� J 6,1Date �` l ' `
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
rformance of the work for which this permit is issued. Sq.Ft Floor Area: Valuation:$2500
` have and will maintain Worker's Compensation Insurance,as provided for by
lv` Section 3700 of the Labor Code,for the performance of the work for which this APN Number:32648011 00 Occupancy Type:
permit is issued.
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 WI I 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 DASY CALLED INSPECTION.
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the Issued b Date.
granting of this permit. Additionally,the applicant understands and will comply y'
with all non- oint source regulations per the Cupertino Municipal Code,Section
9 18. C
RE-ROOFS:
SignatureDate 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
Signature of Applicant: Date:
I hereby affirm that I am exempt from the Contractor's License Law for one of
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. I 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 witthe upertino Municipal Code,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sehcti 25505,25 ,a 25534
Section 3700 of the Labor Code,for the performance of the work for which this l L
Owner or authorized agent: / Date----
1>._
permit is issued.
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 CONSTRUCTION LEDING AGENCY
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 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
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
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
= GENERAL PERMIT APPLICATION MEP
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO,CA 95014-3255 u
(408),777-3228•FAX(408)777-3333•building aacuoertino.org 1 OMISC�
❑PLUMBING ❑MECHANTICALECTRICAL []MISCELLANEOUS
PRO CT AD APN# C5?_,Cp A/0
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OWNIERNAME 6orwy qk e-loog
Y�Ur� �� EMAIL
STI EETADD% e CITY,STFpTE,ZIP. U L� C J* I FAX
CONTACT NAME t / �/]-�„L� PHONEIy 'g`� �// E-MAIL
STREET ADDRESS. �J O 1 r 'J CITY.STATE, q els-6 2 0 FAX
❑ OWNER '❑ OVATIER-BUIIAER ❑ O'MURAGEAf CONIRACrOR ❑CONTRACTORAGENT ❑ ARCHITECT ❑ENGNUM ❑ DEVES,OPOL ❑ TENANT
CONTRACTOR NAME \ LICENSE NUMBER73S9LICENSE TYPE P BUS.LIC#
COMPANYN I'gICGrI'"llJ E MAILFAX
yjh°Tbe tV
STREET ADD 7E.lS � i f � ��` CITY,STATE Z `/� /�� CY �,/� PHO d�1/�7�(/�
ARCHITECT&NGINEER NAME LICENSE NUMBER ( t� ` Gfiv BUS.LIC# 7 / Z
COMPANY NA ME E MAII FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF ❑SFD.,DUPLEX ❑ MtII.T!-FAMQ Y PROJECT IN WII ULAND ❑ YES PROJECT IN ❑YES IS THE BLDG AN ❑-ITS
BUR-DING: COMMERCIAL URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑NO EICHLER HOME? ❑ NO
DESCRIPTION OF WORK
TOTAL VALUATION: RECAf
ELVED
By my signature below,I certify to eac f following: I e property o .or authorized aeent to act on the property owner's be a . have read this
application and the information I have roJ ded is correct. I ere cription of Work and verify it is accurate. I agree to comply vrith all applicable local
ordinances and state lays relating to it ng construction. utho ize re sen ' es of Cupertino to enter the above-identified property for inspection purposes.
Signature of Applicant/Agent- Date:
r�
S PLEMENTAL INFORMATION REQUIRED � EoPUT
c�xls on
RIM
- _
ST.ATi'D�ARD _
m' 2. m Wig'
MEFMisc4pp_2011.doc revised 06/21/11
CITY OF CUPERTINO
FEE ESTIMATOR—BUILDING DIVISION
ADDRESS: 10465 dempster ave DATE: 02/04/2014 REVIEWED BY: Mendez
APN: BP#: "VALUATION: 1$2,500
*PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration / Repair
PRIMARY SFD or Duplex PENTAMATION 1REAP2
USE: p PERMIT TYPE:
WORK Panel upgrade 200 am
SCOPE
I'',; I'izrmt. t'{urr "heed Elec.Plan Check 0.0 hrs $0.00
1icr�. Pcrwi!Fee: Plumb. Pca,mit PecElec.Permit Fee: 1EPERMIT
Otlwr P anb 7r'isP. 0 Other Elec.Insp. Ll hrs $47.00
. -ei", llhinthTr:;p.
NOTE: This estimate does not include fees due to other Departments(i.e.Planning,Public Works,Fire,Sanitary Sewer District,School
District,etc . These ees are based on the prelimina information available and are onl an estimate. Contact the De t or addn 7 info.
FEE ITEMS (Fee Resolution 11-053 Ef. 7/1/13) FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 200 amps Electrical
Suppl. PC Fee: (E) Reg. 0 OT 0.0hrs $0.00 $47.00 IBELEC200 Services
PME Plan Check: $0.00
Permit Fee: $0.00
Suppl. Insp. Fee: Reg. 0 OT 0,0 hrs $0.00
PME Unit Fee: $0.00
PME Permit Fee: T-F $47.00
CCJnso-fiction tF:k
Administrative Fee: 1ADMIN $44.00
Work Without Permit? 0 Yes Q No $0.00 E)
Advanced Planning F ee: $0.00 Select a Non-Residential
Travel Documentation Fee: ITPA VDOC $47.00 Building or Structure ,
Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item
Blda Stds Commission Fee: IBCBSC $1.00
.�
$139.50 $47.00 TOTAL FSE: ; $186.50
Revised: 01/15/2014