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10020017 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 7818 ROBINDELL WAY CONTRACTOR:TBD-TO BE DETERMINED PERMIT NO: 10020017 OWNER'S NAME: JAMES&MARILYN HARSHMAN DATE ISSUED:02/02/2010 T ER'S PHONE: 4083945019 PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT I— PLUMB r License Class �/o Lic.# �� MECH RESIDENTIAL COMMERCIAL Contractor Date ID I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:UPGRADING ELECTRICAL PANEL TO 200AMP;AI (commencing with Section 7000)of Division 3 of the Business&Professions ELECTRIC PD FOR BUS LIC 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. 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:$2800 permit is issued. APPLICANT CERTIFICATION APN Number:36219032.00 Occupancy Type: I certify that I have read this application and state that the above information is correct.I agree to compiy 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 LAST CALLED INSPECTION. with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. _ l p \/ / Date: "2= Signature �/-� Date,9WZ0 Issued by' OWNER-BUILDER DECLARATION RE-ROOFS: I 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 being installed.If a roof is the following two reasons: installed without first obtaining an inspection,I agree to remove all new materials for 1,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: 1,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 I 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 I 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. I 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(a)should I 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 I 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 mustO}yrter�r a iz entl forthwith comply with such provisions or this permit shall be deemed revoked. Dat CONSTRUCTION LENDING AGENCY APPLICANT CERTIFICATION I 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.I 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 aAmnify and keep harmless the City of Cupertino against liabilities,judgments, Lender's Address ,and expenses which may accrue against said City in consequence of the E, nting of this permit.Additionally,the applicant understands and will comply ARCHITECT'S DECLARATION with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. I understand my plans shall be used as public records. Signature Date Licensed Professional CITY OF CUPERTINO 5 ITEMS OF 5 PERMI" RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot:. APN 36:?19032 . 00 DATE ISSUED. . . . . . . : 02 /02/2010 RECEIPT #. . . . . . . . . : BS )00009669 REFERENCE ID # . . . : 10 )20017 SITE ADDRESS 7818 ROBINDELL WAY SUBDIVISION . . . . . . CITY CU?ERTINO IMPACT AREA . . . . . . OWNER JAMES & MARILYN HARSHMAN ADDRESS 7818 ROBINDELL WAY CITY/STATE/ZIP . . . : CUPERTINO CA, CA 95014-5015 RECEIVED FROM AI ELECTRIC CONTRACTOR TBD - TO BE DETERMINED LIC # 00096 COMPANY TBD - TO BE DETERMINED ADDRESS . . . . . . . . . . CITY/STATE/ZIP . . . : TELEPHONE . . . . . . . . FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- --- 1BCBSC VALUATION 2, 800 .00 1 . 00 0 .00 1 . 00 0 . 00 1BSEISMICR VALUATION 2, 800 . 00 0 .50 0 . 00 0 . 50 0. 00 1EPERMITFE FLAT RATE 1.00 42 . 00 0 .00 42 . 00 0 . 00 1ERT<200 UNITS 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 127.50 0 .00 127.50 0 . 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CHECK 127.50 1003 --------------- TOTAL RECEIPT 127.50 CITY OF CUPERTINO CITY OF CUPETRINO GENERAIBUILDING PERMIT-APPLICATION FORM APN # f Date: Building Address: \ Mailing Address (if different from building address): Are Hazardous Materials being used as part of this project? Yes No HOA: (Exterior work onl ) Yes ❑ No If yes, provide letter from HOA Owner's Name- Phone#: s a _q kmom o Contractor: Phone: /0 )_Y3(Z K C 'e J R C Fax: Contractor License#: f j 4* Cupertino Business License#: Contact: Phone: Fax: Residential Commercial ❑ Job Description: Building Permit Info: / Bldg ❑ Elect Plumb ❑ Mech ❑ Type of Construction (Usage Class): Occupancy Type: 1-A, 1-B ❑ II/III/V-A ❑ I1/III B, IV-HT, V-B -- - Valuation: '> Square Footage- Project Size: Express' �andard ❑ Large ❑ Major ❑ Green Building: Please complete relevant portion of the Green Building/LEED Checklist& attach it to the application or if applicable,include in plan set& the sheet index. Points Achieved: For help, contact Build it Green at www.builditreen.or Revised 07/14/09 SfMCITY OF CUPERTINO CU CITY OF O GENERAL BUILDING APPLICATION FEE SCHEDULE Quantity/Sf Fee ID Fee Des,.-ription Fee Permit Type Group 1GENRES or 1GENCOM 1STUCOAP Stucco Applications (up to 400 sf) B additional stucco application 1 WINREP Replacement windows/sliding glass B door (ea 8 windows) 1 WINMEWSTR New Window-structural shear B wall/mas (includes plan ck fee) IEPERMITFEE Electrica. Permit Fee E 1 MPERMITFEE Mechani-;al Permit Fee M 1PPERMITFEE Plumbing;Permit Fee P 1 ELCPLNCK Stand Al)ne Electric Pln Ck(hourly) E 1 MECPLNCK Stand Al ane Mechanical Pln Ck (hrly) M 1 PLMBLNCK Stand Al ane Plumbing Pln Ck(hrly) P 1 STPLNCK-(3 Hr Min Standard Plan Check (when no E/M/P) B when not over counter) hourl -st and alone 1BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT TYPES 1BSEISMICR Seismic EZesidential B- 1BSEISMICO Seismic commercial B 1 TRAVDOC Travel &. Documentation B 1BUSLIC BusinesE License B 5 of 5 Community Development 10300 Torre Avenue ` Cupertino CA 95014 Telephone(408)777-3228 CITY OF Fax(408)777-3333 ;UPEkTINO Building Department JOB ADDRES PERMIT # w OWNER' NAME: PHONE #c �' GENERAL CONTRACTOR: FAX # I am not using any subcontractors: Si;nature 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 Ornamental Sheet Metal Painting/ Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile v OwnerfContractor Signature Date