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11040038 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 22321 CUPERTINO RD CONTRACTOR:A-I ELECTRICAL PERMIT NO: 11040038 CONTRACTING, INC OWNER'S NAME: GARDNER DEANE A AND FUJIMOTO S 1819 POLK ST STE 236 DATE ISSUED:04/06/2011 NER'S PHONE: 4082036792 SAN FRANCISCO,CA 94109 PHONE NO:(415)573-5522 ❑ LICENSED CONTRACTOR'S DECLARATION r- f— BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class C— k Lic.# r— f-" f— MECH RESIDENTIAL COMMERCIAL Contractor A� \ �,ec- v,V,C_,Mt Date I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION: ADD 40 AMP(240 VOLT)CIRCUIT,INSTALL EV CHARGER (commencing with Section 7000)of Division 3 of the Business&Professions IN GARAGE 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 performance of the work for which this permit is issued. Sq.Ft Floor Area: Valuation:$900 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:32616082.00 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 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 DAYS FROM LAST 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 granting of this permit. Additionally,the applicant understands and will comply Issued by: Date: with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. RE-ROOFS: Signature Dat CL) 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. LJ OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for one of Signature of Applicant: Date: 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 the Health&Safety Code,Sections 25505,25 ,and 25534. Section 3700 of the Labor Code,for the performance of the work for which this ' Owner or authorized agent: Date: 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 Compensation laws of California. If,after making this certificate of exemption,I CONSTRUCTION LENDING AGENCY 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 unon the above mentioned property for inspection purposes.(We)agree to save ARCHITECT'S DECLARATION mnify and keep harmless the City of Cupertino against liabilities,judgments, -s,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 5 ITEMS OF 5 PERMIT RECEIPT OPERATOR: SylviaM COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN . . . . . . . . : 32616082 . 00 DATE ISSUED. . . . . . . : 04/06/2011 RECEIPT #. . . . . . . . . : BS000013109 REFERENCE ID # . . . : 11040038 SITE ADDRESS . . . . . : 22321 CUPERTINO RD SUBDIVISION . . . . . . CITY . . . . . . . . . . . . . . CUPERTINO IMPACT AREA . . . . . . OWNER . . . . . . . . . . . . : GARDNER DEANE A AND FUJIMOTO S ADDRESS . . . . . . . . . . CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-1043 RECEIVED FROM . . . . : DBA A-1 ELECTRIC CONTRACTOR . . . . . . . : ROBERT WHITEAKER LIC # 32218 COMPANY . . . . . . . . . . : A-1 ELECTRICAL CONTRACTING, IN ADDRESS . . . . . . . . . . : 1819 POLK ST STE 236 CITY/STATE/ZIP . . . : SAN FRANCISCO, CA 94109 TELEPHONE . . . . . . . . : (415) 573-5522 FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- ---------- 1BCBSC VALUATION 900 . 00 1 . 00 0 . 00 1 . 00 0 . 00 1BREMMISC EACH 1 . 00 126 . 00 0 . 00 126 . 00 0 . 00 1BSEISMICR VALUATION 900 . 00 0 . 50 0 . 00 0 . 50 0 . 00 1EPERMITFE FLAT RATE 1 . 00 42 . 00 0 . 00 42 . 00 0 . 00 1TRAVDOC FLAT RATE 1 . 00 42 . 00 0 .00 42 . 00 0 . 00 ---------- ---------- ---------- ---------- TOTAL PERMIT 211 .50 0 . 00 211 . 50 0 . 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CHECK 211 .50 1231 --------------- TOTAL RECEIPT 211 .50 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 304 ROUGH ELECTRICAL 505 FINAL ELECTRICAL 4 CITY OF CUPERTINO FEE ESTIMATOR-BUILDING DIVISION ADDRESS: 22321 Cupertino Rd. DATE: 04/06/2011 REVIEWED BY: jsg APN: BP#: "VALUATION: isV7 r PERMIT TYPE: Electrical Permit PLAN CHECK TYPE: Alteration/Addition/ Repair PRIMARY SFD or Duplex PENTAMATION 1 REAP? USE: PERMIT TYPE: WORK Add 40 am 240 volt circuit and install EV charger in SF res garage SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Special Circuits 1BREMMISC 1 # $126 TOTALS: 1 $126.00 Elec.Plan Check 0.0 1 hrs $0.00 Elec.Permit Fee: IEPERMIT Other Elec.Insp. 0.0 1 hrs $42.00 NOTE: Thesefees are based on the preliminary in ormation available and are only an estimate. Contact the De t or addn 7 info, FEE ITEMS (Fee Resolution 09-051 Lf T'l.-1 o) FEE QTY/FEE MISC ITEMS PME Plan Check: $0.00 PME Unit Fee: $126.00 PME Permit Fee: $42.00 Work Without Permit? 0 Yes No $0.00 Travel Documentation Fee: 1TRAVDOC $42.00 Strom Motion Fee: $0.00 Select an Administrative Item Bldg Stds Commission Fee: $0.00 ', `�. SUBTOTALS: 1 $210.00 $0.00 TOTAL FEE: 210.00 Revised: 01/15/2011 Building Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014-3255 Telephone: 408-777-3228 CUPERTINO Fax: 408-777-3333 CONTRACTOR/ SUBCONTRACTOR LIST JOB ADDRESS:ZZ--6-2_\ Cc,J k-%.,o 12 , PERMIT# \ -4(= © OWNER'S NAME:lC>ec,,ve PHONE# A\S -- -1•�_'-!5 CD GENERAL CONTRACTOR:A SXe�r,;r CjQ_ BUSINESS LICENSE# ADDRESS: \Q1C-N ?o\k k,- 4F 2 Cc,. CITY/ZIPCODE: Iq A l C;' *Our municipal code requires all businesses working in the city to have a City of Cupertino business license. NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE GENERAL CONTRACTOR AND ALL SUBCO RACTORS HAVE OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE. l I am not using any subcontractors: Si ature Date Please check applicable subcontractors and complete the following information: SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets & Millwork Cement Finishing Electrical Excavation Fencing Flooring/ Carpeting Linoleum / Wood Glass / Glazing Heating Insulation Landscaping Lathing Masonry Painting/ Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile Owner ontractor Si ature Date GENERAL PERMIT APPLICATION MEP COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 Lis (408)777-3228• FAX(408)777-3333•building(Mcupertino.orq misc CUPERTINO / S- APN PLUMBING ❑MECHANICAL ELECTRICAL ❑MISCELLANEOUS //&' i�d�PROJECT ADDRESS ^) �7 l ��\ O �G` # •/ 1 �J / ^ J I&�7 / r OWNER NAME PHONE E-MAIL J STREET ADDRESS �C.�tV�CJ CITY.STATE.ZIP � 0 FAX CONTACT NAME +` S PHONE E-MAIL ��Y•(1-P � STREET ADDRESS CITY,STATE,ZIPF(Gj•4-41 ❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT CONTRACTOR NAME ` V\.I LICENSE NUMBER LICENSE TYPE C-1 o BUS.LIC# COMPANY NAME wE-MAIL FAX STREET ADDRESSCITY,STATE,ZIP PHONE ��1 ��11rC 23Co ��-, C 1::) A1S ��3 ARCHITECTIENGINEER NAME N A LICENSE NUMBER BUS.LIC# COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE ]SE OF SFD or Duplex ❑ Multi-Family PROJECT IN WILDLAND PROJECT IN STRUCTURE: ❑ Commercial URBAN INTERFACE AREA ❑ Yes a IV O FLOOD ZONE ❑ Yes p"lgo6 DESCRIPTION OF WORK ^ \ Z 4(D Y-, TOTAL VALUATION: W �� RECEIVED BY By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on the property owner's behalf. 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 b ildin constru n. I authorize representatives of Cupertino to enter the above-identified property for inspection purposes. Signature of Applicant/Agent: Date: A t0 k , SUPNZ,YENTAL INFORNq419UIRED eic> asp oNi , E1VER TIM ' �* 1PRESS ❑'fAJOK MEPMiscApp_2011.doc revised 03/16/11