15040106 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10470 SERRA ST CONTRACTOR:ANTHONY LEWIS PERMIT NO:15040106
OWNER'S NAME:
SAN JOSE,CA 95125 PHONE NO:(408)217-8621
❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL COMMERCIAL
]�
11 INSTALL 240 VOLT 50 AMP CIRCUIT;NEMA OUTLET
License Class �D Lic.# \l LFOR
FUTURE EV CHARGING STATION
Contractor ✓ Date
I hereby aff►rm that I a icensed under the provisions f Cha ter 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 ave and will maintain a certificate of consent to self-insure for Worker's
ompensation,as provided for by Section 3700 of the Labor Code,for the Valuation:$1100
erformance of the work for which this permit is issued. Sq.Ft Floor Area:
AW-aadwill maintain Worker's Compensation Insurance,as provided for by
bion 3700 of the Labor Code,for the performance of the work for which this APN Number:34259011.00 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 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 180 DAYS F LAST CALLED IN CTION
SP .
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the Issued by: Date:
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. RE-ROOFS:
Signature Date-kq <1 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-BUILD DECLARATION Signature of Applicant: Date:
I hereby affirm that I am exempt from the Contractor's License Law for one of ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
the following two reasons:
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) HAZARDOUS MATERIALS DISCLOSURE
I,as owner of the property,am exclusively contracting with licensed contractors to
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
will maintain compliance with the Cupertino Municipal Code,Chapt 9, and
performance of the work for which this permit is issued.
the Health&Safety Code,Sections 25 rel 25534.
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 Owner or authorized age, . Date:` `t
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
work's for which this permit is issued(Sec.3097,Civ C.)
forthwith comply with such provisions or this permit shall be deemed revoked. 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
918.
Signature Date
CITY OF CUPERTINO
10 FEE ESTIMATOR—BUILDING DIVISION
ADDRESS: 10470 serra st DATE: 04/14/2015 REVIEWED BY: Sean
APN: BP#: *VALUATION: $1,100
*PERMIT TYPE: Electrical Permit PLAN CHECK TYPE: Alteration/Addition/ Repair
PRIMARY PENTAMATION 1 REAP2
USE: SFD or Duplex PERMIT TYPE: A
WORK install 240 volt 50 amp circuit; nema outlet Ifor future ev charging station
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Services 1 ERT<200 50 Amps $48
1777
TOTALSoil
:' $48.00
� i
p.
Ie A Nor,Check Phimb. Plan Check Elec.Plan Check 0.0 hrs $0.00
Mee,,/r. Permit Fee: Plumb. Permit Fee: Elec.Permit Fee: IEPERMIT
-L--t)fher,tdec°h, lrtsj�. Other Plumb Insp. Li L Other Elec.Insp. 0.0 hrs $48.00
�Vfech Insp. Fee: Plzsmb. hiss. Fee: ISk;c.Inst.'). Fee.:
NOTE: This estimate does not include fees due to other Departments(Le.Planning,Public Works,Fire,Sanitary Sewer District,School
District,eta). These fees are based on the prelimina information available and are on! an estimate. Contact the Dept for addn'l info.
FEE ITEMS (Fee Resolution 11-053 E . 7f� /1/13) FEE QTY/FF MISC ITEMS
Plan Check Fee:
suppl. ft.,Fee
PME Plan Check: $0.00
Perin l t Fee:
suppl. Ins!)Fees
PME Unit Fee: $48.00
PME Permit Fee: $48.00
Construction Tax:
Administrative Fee: ]ADMIN $45.00
Work Without Permit? ® Yes 0 No $0.00
�Jdvanced Plarining Fees:
Travel Documentation Fee: ITRA VDOC $48.00 A
Strong Motion.Fee: IBSEISMICR $0.50 Select an Administrative Item
Bldg Stds Commission.Fee: IBCBSC $1.00
� r �.
4 , aWMMr" ' $190.50 $0.00 ,TO: ALE; $190.50
MEMEM
Revised: 04/01/2015