12100135 CITU OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10290 WESTACRES DR CONTRACTOR:SIMON WU PERMIT N0: 12100135
CONSI'RUCI'ION CO
OWNER'SNA\IE: IIONKAITAM 820 BRUNSWICK ST DATE ISSUED: 10/172012
OWNER'S PBONI,: 6508689350 SAN FRANCISCO,CA 94112 PRONE NO:(415)581 2322
❑ LICENSISD CO\VRAC7FOR'S DECLARA'T'ION
BUILDING PERMIT INFO: BLDG r ELECT r PLUMB (J
License Ch 1% Lie.N
Conlmdor LJDate
D ( 2— DIECII r RESIDENTIAL r COMMERCIAL
I hereby affirm that l am licensed under the provisions of&aptcr9l 30B DESCRIPTION: REMOVE AND REPLACE 100 AMP PANEL
(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 penally of perjury one of the fnllowing two declarations:
I have and will maintain a certificate of consent to self-insure for Worker's
Compensation,i s provided for by Section 3700 of the Labor Code,for the
performance of the work for which this permit is issued. Sq.FI Floor Area: Valuation:$3000
1 have and will maintain Worker's Compensation Insurance,as provided for by
Section 3700 of the Labor Code,for the performance of die work for which this
permit is issued APN Number:35911031.00 Occupancy Type:
APPLICAN r CERTIFICATION
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 PERMIT EXPIRES 1F WORK IS NOT STARTED
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save WITHIN 180 DAYS OF PERMIT ISSUANCE OR
indemnify and keep harmless the City of Cupertino against liabilities,judgments, 180 DAPS FROM LAST CALLED INSPECTION.
costs,and expenses which may accrue against said City in consequence of the
granting of this perout. Additionally,the applicant understands mid will comply n
with all no - urce regulatim cr the Cupertino Municipal Codc,Section Issued by:_ � �iT Date: lCl•/7� ,}
9.18. ( p' JI p ,� V/,-Z
Signature lv avl3 12--� D ( RF-ROOF'S:
❑ OWNER-RUILDER DECLARATION 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
hereby affirm that I am exempt from the Contractor's License Law for one of inspection.
the following lon reasons:
I,as owner of the property,or my employees with wages as their sole compensation. Signature of Appticane Date:
will do the work,and the stricture is not intended or offered for sale(Sce.7044,
Business 8 Professions Code)
1,as owner of the properly,am exclusively contracting With licensed contractors to ALL ROOF COVERINGS TO BE CLASS"A"OR BET`fER
construct the project(Sec.7044,Business K Professions Code).
1 hereby alarm under penalty of perjury one of the following three IIA%ARDOUS MATERIA S DISCLOSURE
declarations: I have read the hazardous materials requirements under Chapter 6.95 of the
I have and will maintain a Certificate of Consent to self-insure for Worker's California Health S Safety Code.Sections 25505,25533.and 25534. 1 will maintain
Compensation,as provided for by Section 3700 of the Labor Code,for the compliance with the Cupertino\lunicipal Code,Chapter 9.12 and the 1lcalth S
performance of the work for which this permit is issued. Safely Code,Section 25532(x)should I store or handle hazardous material.
I have and will maintain Worker's Compensation Insurance,as provided for by Additionally,should I use equipment or devices which emit hazardous air
Section 3700 of the Labor Code,for the performance of the work for which this contaminants as defined by the Bay Area Air Quality Management District I will
permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
1 certify that in the performance of the work for which this permit is issued.I shall Ilcalth S 'alcly Code.Sections 25505,25533,and 25534.r
not employ any person in my manner so as to become subject to the Worker's Owner o t�razed agent
Compensation paws of California. If,after making this cenificate of exemption,I iJ14 A1AA'-1 �,1U—Date: �-
become subject to the Worker's Compensation provisions of the Labor Code,I must
forthwith comply with such provisions or this permit shall be deemed revoked CONSTRUCTION LF.NDb\G
I hereby afrnn that there is a construction pending agency for the performance of work's
APPLICANT CER'1'II'ICATION for%%Inch this permit is issued(Sec.3097,Civ C.)
I certify that I have read this application mid state that the above information is Leader's Name
correct.I agree to comply wish all city and county ordinances and state laws relating
to building construction,and hereby authorize representatives of city to enter Lender's Address
upon the above mentioned property for inspection purposes.('Ale)agree to save
indemnify and keep harmless the City of Cupertino against Iiabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the ARCB ITECI"S DECLARATION
granting of this permit.Additionally,the applicant understands and will comply I understand my plans shall be used as public records.
with all non-point source regulnticns per the Cupertino Municipal Code,Section
9.18. Licensed Professional
Signature Date
GENERAL PERMIT APPLICATIq.NT M E r
COMMUNITY DEVELOPMENT DEPARTMENT- BUILDING ISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 Ow
CUPERTINO (`08)777-3228 • FAX(408)777-3333 • buil�ding0cuoerino.ora '�I
ISC
❑PLUMBING ❑MECHANICAL fFLEC TICAL m l�❑/lMMISCELLLANFOUS /�
PRO=ADDRESS 0S
DWNER NAME PHONE 68 935 EMAIL, 1
STREET ADDRESS (� CTTY, STATE,ZIP o J I I FAX
CONTACT NAME PHONE E-MAIL
S,(TREET ADDRESS I CTTY,STATE, ZIP FAX
VJ OwxER. ❑ OWNER.BLTLDER ❑ OWNER AGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME 1 I , LICENSE Nt1MHER / ucicNIE TYPE I BUS.LC d
COMPANY NAME w I E-MAIL 62 - FAX
S 1
STREET ADDRESS D / L I CfTY.STATE,ZIP
1
HONg0
b l_ b 7u
ARCHTTECVENGINEER NAME LICENSE NUMEER I BUS.LIC n
COMPANYNAME' I E-MAIL FAX
STREET ADDRESS I Crv,STATE,ZIP PHONE
USE OF ZKF .DUPLZX ❑ MULTI-FAMILY PROJECT IN WILDLATD ❑ YES PRO=III ❑vEs ISTHEBLDGAN [3YEs
BUILDP'G: �COMMERCW. URBAN PTcRFACEAREA 'gJ+O FLOOD LANE Q,NO E1CTll.ER HOME? 19W0
DESCRIPTION OF WOR% O /
TOTAL VALUATION: I RECEIVEDBY:
By my signature below,I certify to each of the following: I am the proper y owner or authorized agent to act on the property owner's behalf. 1 have read this
application and the information I have provided' correct. 1 have crip[ion of Work and verity it is accurate. 1 agree to comply with BII applicable local
ordinances and state laws relating m bull nsvuc I authonu representatives of Cupertino to enter the above-idcntil6Jed property for inspection pui'boses.
Signature of ApplicanOAgcnt Date: 101471'g-ot-z
SUPPLEMENTAL 'MATION REQUIRED OFFICE USE ONLY
v OSIS 'ER-THE.COUNTER
r
❑ EXPRESS
u ❑ STANDARD
G
< ❑ LARGE
❑ MAJOR
dg'PAfucApp2011.doc revised 06121/11
CITY OF CUPERTINO
FEE ESTIMATOR- BUILDING DIVISION
ADDRESS: 10290 Westacres Dr DATE: 10/17/2012 REVIEWED BY: Sean
APN: RPH: 11100206 'VALUATION: $3,000
*PERMIT TYPE: Electrical Permit PLAN CIIECK TYPE: Alteration /Addition / Repair
PRIMARY SFD r Duplex PENTAMATION 1REAP2
USE: PERMIT TYPE:
WORK Revi • n 1: Remove and replace 100 amp panel.
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Services 1ERT<200 100 Amps $45
TOTALS: $45.00
,Llech. Plan Check Plumb. Plan Cheek Elec. Plan Check 1 0.0 1 hrs $0.00
Aleeh. Permit Fee: Phtmh. Permit Fec: Elec. Permit Fee: IEPERA-IIT
Other,tlech. Insp. Other Plumh Insp. Other Elec. Insp. 0.0 hrs $45.00
Alech.insp.Fee: Plumb. htvp.Fee: Elee.Lisp.Fee:
NOTE: This estinmte does not include jeer due to other Departments(i.e. Planning, Public Works, Fire,Sanitary Sewer District,School
District, etc. . Thesefees are baser/an the prelintinart information available and are onh,an estimate. Contact the Delujor addn7 into.
FEE ITEMS (bee Rcsolwion 11-053 E2 7/1/12) FEE QTY/FEE MISC ITEMS
Pltri Check Fee:
Snppl. PC Fee
PME Plan Check: $0.00
Permit Fee:
Supp/. lisp Fee
PME Unit Fee: $45.00
PME Permit Fee: $45.00
Consmtction Tar:
Administrative Fee: lADHhV $42.00
Work Without Permit? Yes Q No $0.00
Advanced Planning Fees:
Travel Documentation Fee: ITRA VDOC $45.00 A
Strong Motion Fee: IBSEISHICR $0.50 Select an Administrative Item
131de,Stds Commission Fee: IBCBSC $1.00
SUBTOTALS: $178.50 $0.001 TOTAL FEE: $178.50
Revised: 10/01/2012