13070158CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10510 N STELLING RD
CONTRACTOR: TV GENERAL
PERMIT NO: 13070158
CONTRACTOR
OWNER'S NAME:
SAN JOSE, CA 95126
PHONE NO: (408) 802-9209
JOB DESCRIPTION: RESIDENTIAL 11COMMERCIALE]
❑, LICENSED CONTRACTOR'S DECLARATION
License Class # cS S_Z7 3 a--
INSTALL TEMPORARY POWER POLE
/%Lic.
Coe— bl'?' 7) / /.�
Contractor Date
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
Sq. Ft Floor Area:
Valuation: $200
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
APN Number: 32630101.10510
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
WITHIN 180 DAYS OF 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 DAYSJEROULAST 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
Is te:
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. f "
RE -ROOFS:
Signature t 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.
❑ 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
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 with the Cupertino Municipal Code, Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance, as provided for by
for for this
the Health & Safety Code, Sections 33, and 25534.
/2
Section 3700 of the Labor Code, the performance of the work which
Owner or authorized agent: Dater 3
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 LENDING 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
CITY OF CUPERTINO
FEE ESTIMATOR - BUILDING DIVISION
APPLIANCE / EQUIP TYPE
ADDRESS: 10510 STELLING
QTY/FEE
DATE: 07/24/2013
REVIEWED BY: MELISSA
BP FEES
APN: 326 30 101
BP#:
1 ERT<200
*VALUATION: $200
xPERMIT TYPE: Electrical Permit
PLAN CHECK TYPE: Alteration / Addition / Repair
PRIMARY SFD or Duplex
USE:
PENTAMATION 1REAP14
PERMIT TYPE:
WORK
INSTALL TEMPORARY POWER POLE
SCOPE
APPLIANCE / EQUIP TYPE
FEE ID
QTY/FEE
QTY
UNITS
BP FEES
Elec. Permit Fee: IEPERMIT
Temporary Power
1 ERT<200
Other Elec. Insp. 0.0 hrs $47.00
100
Amps
$47
f
PME Unit Fee:
$47.00
PME Permit Fee:
$47.00
Administrative Fee: ]ADMIN
$44.00
Work Without Permit? 0 Yes E) No
$0.00
TOTALS:
Travel Documentation Fee: ITRA VDOC
$47.00
Strom Motion Fee: ]BSEISMICR
NOTE. This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School
District. ete.). These fees are based on the nreliminary information available and are only an estimate Contact the Dent for addn'1 info_
FEE ITEFMS (ee Resolution 11-053 Eft.' 7/1/12)
FEE
QTY/FEE
Elec. Plan Check 1 0.0 1 hrs $0.00
p
Elec. Permit Fee: IEPERMIT
;It s tr 1 'ee
tt '�_�� T� ,�i fr.>�
Other Elec. Insp. 0.0 hrs $47.00
V-",JC�
, x v
NOTE. This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School
District. ete.). These fees are based on the nreliminary information available and are only an estimate Contact the Dent for addn'1 info_
FEE ITEFMS (ee Resolution 11-053 Eft.' 7/1/12)
FEE
QTY/FEE
MISC ITEMS
p
;It s tr 1 'ee
PME Plan Check:
$0.00
f
PME Unit Fee:
$47.00
PME Permit Fee:
$47.00
Administrative Fee: ]ADMIN
$44.00
Work Without Permit? 0 Yes E) No
$0.00
Travel Documentation Fee: ITRA VDOC
$47.00
Strom Motion Fee: ]BSEISMICR
$0.50
Select an Administrative Item .
Bldg Stds Commission Fee: IBCBSC
$1.00
SUBTOTALS: 1
$186.501
$0.00 TOTAL FEE:
$186.50
Revised: 07/01/2013