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11110175
t CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 20833 FARGO DR , ,CONTRACTOR:HAYNES BUILDERS PERMIT NO: 11110175 OWNER'S NAME: NANCY A KATO 56 CHERRY LN DATE ISSUED: 11/30/2011 ER'S PHONE: 4086552539 CAMPBELL,CA 95008 PHONE NO:(408)8216811 LICENSEDCONTRACTOR'S DECLARATIONCl I—_- 17_5 - BUILDING PERMIT INFO: BLDG ELECT ,PLUMB License Class - LicA • 6&0.51/0 r [� MECH RESIDENTIAL COMMERCIAL Contractor Date 1-hereby alit that 1 ameeused under the provisions of Chapter 9 JOB DESCRIPTION:TWO(2)RECEPTICLE OUTLETS FOR MOTION (commencing with Section 7000)of Division 3 of the Business&.Professions SENSORS/CAMERAS 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,m 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 the work for which this Sq.Ft Floor Area: _ Valuation:$500 permit is issued. APPLICANT CERTIFICATION APN Number:32630131.00 Occupancy Type: I certify that I have read this application and state that the above information is correct.1 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 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 LAS ALLED INSPECTION. with all non-poi urce regulations per the Cupertino Municipal Code,Section 9.18. Issued by: Date: Signature ., Date //—�0_/r � I•w � eT • 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 1 hereby affirm under penalty of perjury one of the following three declarations: HAZARDOUS MATERIALS DISCLOSURE 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 1 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(x)should l store or handle hazardous material. Additionally,should I use equipment or devices which emit hazardous air permit is issued. contaminants as defined by the Bay Area Air Quality Management District 1 will I certify that in the performance of the work for which this permit is issued,I 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 Ow er r•outr' ed agent: forthwith comply with suchprovisions or this permit shall be deemed revoked. Date:/ APPLICANT CERTIFICATION CONSTRUCTION LENDING AGENCY 1 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.t 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 AM and expenses which may accrue against said City in consequence of the Vang of this permit.Additionally,the applicant understands and will comply -ARCHITECT'S DECLARATION . ll non-point 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 7 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN . . . . . . . . : 32630131.00 DATE ISSUED. . . . . . . : 11/30/2011 RECEIPT #. . . . . . . . . : BS000015443 REFERENCE ID # . . . : 11110175 SITE ADDRESS . . . . . : 20833 FARGO DR SUBDIVISION . . . . . . . CITY . . . . . . . . . . . . . : CUPERTINO IMPACT AREA . . . . . . . OWNER . . . . . . . . . . . . : NANCY A KATO ADDRESS . . . . . . . . . . : 20833 FARGO DR CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM . . . . . HAYNES BUILDERS CONTRACTOR . . . . . . . : JIM HAYNES LIC # 31658 COMPANY . . . . . . . . . . : HAYNES BUILDERS ADDRESS . . . . . . . . . . : 56 CHERRY IN CITY/STATE/ZIP . . . : CAMPBELL, CA 95008 TELEPHONE . . . . . . . . : (408) 823-6811 • FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW SAL ---------- ------------- ---------- ---------- ---------- ---------- ---------- -ADMIN HOURS 1.00 41.00 0.00 41.00 0.00 1BCBSC VALUATION 500.00 1.00 0.00 1.00 0.00 1BREMRECEP NO. OUTLETS 1.00 44.00 0.00 44.00 0.00 1BSEISMICR VALUATION 500.00 0.50 0.00 0.50 0.00 1EPERMITFE FLAT RATE 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 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 304 ROUGH ELECTRICAL 505 FINAL ELECTRICAL 512 FINAL HANDI-CAP GENERAL PERMIT APPLICATION M E P COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO,CA 950143255 •CUPERTINO (4G8)7773228-FAX(408)777-3333•buildinci(G.cuoerdno.0m m 1 S C FlmulMBING ❑MECAANICAL [IMECMCAI/ryryry� ryry ❑MMCEISANEOUS PBOIECTAMR13S 2er.7 3 OYDMNAMffi FE 6 WMAM STREEYADDRM ,STATE.Z@ FAX CONTACT HAMS FROM E-MAM Tr APS SISEETADDR= / srAT$.ZW C4 9<00t 2 n p awm p owmt-m=ER p OWNERAOENT crag pamTRAcmRAaetrr ❑ AR== 13FN=4= p DEmom 13 Tatar CONTRACTOANAMH _ 11 NOMHER IJ TYPE Mmucs D COMPANYNAME 93Z staEETADnaEs9 4,142 C ` 'c48 ARfffiTRCClSNOSIEFB LXM49ENUA3ER mmucs COMPANYNAMS' E-MAIL FAX R>PATDTODxREoSFS CIY.STATE.Z@ PROM t7op M umn-mmy PROISCTWWdDIAND p YE9 PRmwriN p YES; VITEEBLDaAN p YES FaFE a URRANDMENFACEAREA R _ // r TOTAL VALTIATRIN: RSCEIVEO BY: By my sig mMM below,I cmtify to each of the WoWiag: I sen the property owner ar andurrimcl agent to act oc the property owner's bahaX I have read this application sad the ivfannatt®I vided is conect4;Imve teadthe Descriptim of Work and verify it is accmete. I agree to comply with aH applicable local ordfusnow andamts IX raladag Id{v�cons cdoa Iaot4 fm rcpreamtathwofC>apartiictovoterthcabove-idmdBedptopmiyfbrkq cdoapernioses. SignemmofApplicmWAgeaR` / Date: S?"LEMEllT4x INFORMATION REQUIRED OFFICE U&S ONLY yt ❑ OYER-TRR-4COE?4TER ��q$ ❑ BXPRESS ❑ STANDARD 6 ❑ LARGE ❑ MAJOR AaPAfrcdpp 2011.docrevised06121111 I I I 1 0 1 -7 CITY OF CUPERTINO FEE ESTIMATOR-BUILDING DIVISION • ADDRESS: 20833 Fargo Drive DATE: 11/30/2011 REVIEWED BY: larry s APN: I BP#: "VALUATION: $500 'PERMIT TYPE: Electrical Permit PLAN CHECK TYPE: Alteration I Addition/Repair USES: ARY SFD or Duplex PERRMIITTYYPE:NTAATIN 1 REAP10 woRK 2 rete title outlets for motion sensors/cameras SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Recep/Switch/Outlets 1BREMRECEP 2 # $44 TOTALS: $44.00 Be•R. pian Chi-ct Nandi, Plan Check Elec.Plan Check 0.0 hrs $0.00 h11,11 Aern,it Fee- plumb.pemi7 Fee: I Elec.PCttllit FCC: IEPERHIIT clNrcr,ilerlt.Insp. 01110r Phaub lzrsp. Other Elec.Insp. 0.0 ins $44.00 VeJz.Iny. Fee: Plwrh. Gasp.Fen; Etre.Ince. Pee: NOTE:This estimate does not lndude fees due to other Deparitwx s(La Planning,Public Works,Fire,Sanboy Sewer District,School etc.). Thesefees are based on the relim orn don available and are only an esthnate. Conrad the Dept for addn'l lot& FEE ITEMS(Fee Resolution 11-033 E . 711111) FEE QTY/FEE MISC ITEMS Plan Check Fec: suppl. PC'Fee PME Plan Check: $0.00 PCrntir r<.z. ,3npp1. 1n.5p Fee PME Unit Fee: $44.00 PME Permit Fee: $44.00 (,owt wcfhm Inc Administrative Fee: IADMIN $41.00 Work Without Permit? © Yes (D No $0.00 � h.zzncc<l Planning F'ce5 Travel Documentation Fee: I MVDOC $44.00 Strong Motion Fee: ISSE1SMtCR $0.50 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $1.00 SUBTOTALS; $174.50 $0.00 TOTAL FEET $174.50 Revised: 10/0112011