13020106 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 23016 VOSS AVE CONTRACTOR:VOLTZ ELECTRIC PERMIT NO: 13020106
OWNER'S NAME: SWAMI ARUN N 6245 LEAN AVE DATE ISSUED:0220/2013
OWNER'S PHONE: 4083380906 SAN JOSE,CA 95123 PHONE NO:(408)464-8588
LICENSED CONTRAGTnOR'S SDEECpLARATION JOB DESCRIPTION: RESIDENTIAL LJ COMMERCIAL
EJ
License Class /C� Lie.# INSTALL(4)120V NEW OUTLET RECEPTACLES IN
CRAWL
Contractor 1 blrzZ .rte Date '� D SPACE AREA FOR HUMIDITY FANS
1 hereby affirm that.I am licensed under,the provisions of dhapter 9
(commencing with Section 7000)of Division 3 of the Business&Professions
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 _
perfbrnance of the work for which this permit is issued. Sq.Ft Floor Area: Valuation:$300
I have and will maintain Worker's Compensation Insurance,as provided for by
Section 3700 of the Labor Code,for the peddrmance of the work for which this APN Number:34250018.00 Occupancy Type:
permit is issued. - -
APPLICANT CERTIFICATION -
I certify that I have read this application and state thatthe 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 WITHIN 180 F 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 0 D LAST CAL ED 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 Date- Zd
granting of this it. Additionally,the applicant understands and will comply ue y:
with all non-poi t source regulations per the Cupertino Municipal Code,Section
9.18.
RE-ROOFS:
Signature - Date 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.
O 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
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
constmct 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 ay Area Air Quality Management District I
performance of the work for which this permit is issued. will maintain compliance with th Cupertino Municipal Code,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sectio s 25505,25533,and 25534.
Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agent -- Dater
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 my manner so as to become subject to the Worker's CONSTRUCTION LENDING AGENCY
Compensation laws of Calif imia IT after making this certificate of exemption,I
become subject to the Worker's Compensation provisions of the Labor Code,I must I hereby affirn 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=ANT
and state that the above information is
correct.I agree to comply with all city and.00wty,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 M E P
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION O^ O
10300 TORRE AVENUE•CUPERTINO,CA 95014-3255 M '
sc
CUPERTINO (408)777-3228• FAX(408)777-3333• buildinaCG?Cuoertino.ora
PLUMBING MECHANICAL CIRICAL ❑MISCELLANEOUS
PROJECT ADDRESS \nxAFN# 3 q� _ C O O
OWNERNANE ' PHONE V -( O EMABI
60U AJ Z,)Ajvl I
STREETADDRESS CITY, STATE,ZIP O FAX
G
CONTACT NAME PHONE E-MAIL
STREETADDRESS CITY STATE, ZIP FAX m
❑OwNER ❑ owHER-BunzER ❑ OWNER AGENT 6Y5ONTRACrOR ❑CONTRACTORAGENT ❑ ARCHITECT ❑ENGA'EER ❑ DEVELOPER ❑ TENANT
CONTRACTORNAME LIC /ENUMBER G 'SE TYPE BUS.LIC# /Q/I
t z ` Ol/
COMPANY NAME If E-MAIL FAX
STREETADDRESS ZLl > LTTY TATE, r/Z PHONE
ARCHITECT/ENGINEER NAME LICENSE NUMBER [' BUS.LIC A Y
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF SFD or DUPLEX ❑ MUL11-FAMMY PROJECTIIIWLLDL.ND ❑ YES PROJECT IN ❑YES ISTHEBLDGAN ❑YES
BmI.DDiG: ❑COMMERCVil. URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑NO MCHLER HOMED ❑NO
DESCRIPTION OF WORK
(nJ Y
1-41m
L
1
TOTAL VALUATION: RECEIV
t
By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on the prop a al£ I have read this
application and the information I have provided is correct I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating to buil ng construction. I authorize representatives of Cupertino to enter the above-i entifie prop4&for inspection pu(poses.
Signature of Al.licanVAgenC Date: 2
SUP MENTAL INFORMATION REQUIRED OFFICE USE ONLY
OVER-THE-COUNTER
❑ EXPRESS
Y
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❑ STANDARD
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Z ❑ LARGE
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❑ RIAJOR
MPPMiscApp_2011.doc revised 06127111
CITY OF CUPERTINO
FEE ESTIMATOR—BUILDING DIVISION
ADDRESS: 23016 VOSS AVE DATE: 02120/2013 REVIEWED BY: MELISSA
APN: 342 50 018 BP#: 'VALUATION: $300
*PERMIT TYPE: Electrical Permit PLAN CHECK TYPE: Alteration/Addition / Repair
PRIMARY SFD Or Duplex PENTAMATION 1REAP10
USE:. PERMITTYPE•
WORK INSTALL (4) 120V NEW OUTLET RECEPTACLES IN CRAWL SPACE AREA FOR HUMIDITY FANS
SCOPE
APPLIANCE/EQUIP.TYPE FEE ID QTY UNITS BP FEES
Recep/Switch/Outlets 1BREMRECEP 4 # $45
} TOTALS: * `- w34 •.f $45.00 IF��. t.
Mech. Plan Check Plumb.Plan Check Elec.Plan Check 1 0.0 1 hrs $0.00
,bfech. Permit Fee: Plumb. Permit Fee: Elec.Permit Fee: IEPERMIT
Other Mech. Insp. Other Plumb Insp. Li Other Elea Insp. 0.0 hrs $45.00
:11ech. Insp. Fee: - Plumb. htsp.Fee: Elec.Insp. Fee:
NOTE:This estimate does not include jeer due to other Departments(ice.Planning,Public Works,Fire,Sanitary Sewer District,School
District etc.). These fees are based on the prrellmin information available and are only an estimate. Contact the Dept for addn'l info.
FEE ITEMS(Fee Resolution 11-053 E . 7� FEE QTY/FEE MISC ITEMS
Plan Check Fee:
Supp 1. PC Fee
PME Plan Check: $0.00
Permit Fee:
Suppl. Insp Fee
PME Unit Fee: $45.00
PME Permit Fee: $45.00
Consnitction Tar:
Administrative Fee: IADMIN $42.00
Work Without Permit? O Yes O No $0.00
Advanced Planning Fees:
Travel Documentation Fee: ITRAVDOC $45.00
Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $1.00
$178.50 $0.00 ,1" d �TOTALFEEit. $178.50
�\ Revised: 01/01/2013
Cali • - '�" ci'JT
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