15070200CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10421 LANSDALE AVE
CONTRACTOR: JOHNSTON ELECTRICAL
PERMIT NO: 15070200
CONTRACTOR
OWNER'S NAME: XU WEN AND FANG HAI
1302 LINCOLN AVE STE 204
DATE ISSUED: 07/28/2015
OWNER'S PHONE: 8136215676
SAN JOSE, CA 95125
PHONE NO: (408)266-0236
9-NELICENSED CONTRACTOR'S DECLARATION
JOB DESCRIPTION: RESIDENTIAL COMMERCIAL E]
UPGRADE (E) PANEL TO (N) 200 AMP PANEL
License Class e %V Lic.# 3 75 7��
Contractor_)O//45T,��� EZ4. Date
I hereby affirttf`Ihat'1'am- qTcen�d'dnd6rthe 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: 5900
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: 36911006.00
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 S FROM LAST CALLED INSP CCTT1 N.
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
costs, and expenses which may against said City in consequence of the
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Issued by: Date:
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granting of this permit. A y, the applicant understands and will comply
with all non -point sou re ations per the Cupertino Municipal Code, Section
9.18.
RE -ROOFS:
Signature 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)
1, 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. 1 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 which emit hazardous
Compensation, as provided for by Section 3700 of the Labor Code, for the
air contaminants as defined by the Bay Area ' Qu Management District I
performance of the work for which this permit is issued.
I have and will maintain Worker's Compensation Insurance, as provided for by
will maintain compliance with the Cu o M ' 'pal Code, Chapter 9.12 and
the Health & Safety Code, Sectio 05, 3, and 25534.
Section 3700 of the Labor Code, for the performance of the work for which this
Owner or authorized agen Date: z��Zz
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
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
CUPERTINO
GENERAL PERMIT APPLICATION 15019
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228 • FAX (408) 777-3333 • buildinaacuoertino.oro
❑PLUMBING ❑MECHANICAL FiXLECTRICAL I1MTSCELLA\TEC)TTC
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❑ O1i'1\7ER ❑ OWNTER-BUILDER ❑ OWNERAGENT J11-ONIRACTOR ❑ CONTRACTORAGENT ❑ ARCM ECT ❑ ENGI1,Ma ❑ DEVELOPER ❑ TENANT
CONTRACTO NAME « LICENSE NUh1BER LICERSE TYPE
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BUS. LIC #
COMPANY NAME
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ARCIETECTIENGINEER NAME
LICENSE NUMBER
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COMPANY NAME
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STREET ADDRESS
CITY, STATE, ZIP
PHONE
USE OF SFD or DUPLEX ❑ MULTI -FAMILY. . PROJECT LN W]LDLAND ❑ YES PROJECT IN ❑ YES
BUILDING: ❑ COMMERCIAL I URBAN INTERFACE AREA E] NO FLOOD ZONE ❑ NO
IS THE BLDG AN ❑ yES
EICHLER HOME? ❑ NO
DESCRIPTION OF WORK _ _
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TOTAL VALUATION: /f�
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By my signature below, I certify to each of the foll:m;g,,:
application and the information I have provideI
ordinances and state laws relating to build'
Si�ature of ApplicanUAgent:
IV JK
am the property owner or authorized agent to act on the pr perty owner's behalf. I have read this
have read the Description of Work and verify it is accurate. I a� a to cc ply with all applicable local
tion. ,]authorize representatives of Cupertino to enter the above -idea ed pr erty for inspection purposes.
Date: 7 /S
SufAMENTAL INTFORMATION REQUIRED
�
BICE LSEONLY
_
- -
MEP -A sa4pp_2011.doc remised 06121/11
CITY OF CUPERTINO 15g+00- a.�./
FEE ESTIMATOR — BUILDING DIVISION
APPLIANCE / EQUIP TYPE
ADDRESS: 10421 LANSDALE AVE
DATE: 07/28/2015
REVIEWED BY: PAUL
UNITS
APN: 36911006
BP#:
`VALUATION: $900
xPERMIT TYPE: Electrical Permit
PLAN CHECK TYPE: Alteration / Addition / Repair
PRIMARY
USE: SFD or Duplex
Amps
PENTAMATION
PERMIT TYPE: 1 REAP
WORK
U rade Epanel to N 200 Amp Panel
SCOPE
APPLIANCE / EQUIP TYPE
FEE ID
Plumb. Plan Check
QTY
UNITS
BP FEES
Elec. Permit Fee: IEPERMIT
Services
1 ERT<200
Other Elea Insp. 0.0 hrs $48.00
200
Amps
$48
Per•init Fee:
PME Unit Fee:
$48.00
PME Permit Fee:
$48.00
Construction Tax:
Administrative Fee: (ADMIN
$45.00
Work Without Permit? 0 Yes (F) No
$0.00
TOTALS:
Travel Documentation Fee: ITRA VDOC
$48.00
Strong Motion Fee: IBSEISMICR
NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School
District etG). These fees are based on the vrelimina information available and are on1v an estimate. Contact the Dept or addn'l info.
FEE ITEMS (&e Resolution 11-053 Ef/: 7/1!13)
Mech. Plan Check
Plumb. Plan Check
Elec. Plan Check 1 0.0 hrs $0.00
Plan Check Fee:
Plumh. 1",
Elec. Permit Fee: IEPERMIT
Ocher Aleck. Insp.
�:?thee Plumb 1nsp.
Other Elea Insp. 0.0 hrs $48.00
<! ...
, 3 b.Vee:
$0.00
NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School
District etG). These fees are based on the vrelimina information available and are on1v an estimate. Contact the Dept or addn'l info.
FEE ITEMS (&e Resolution 11-053 Ef/: 7/1!13)
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee:
Supp1. PC' Fee
PME Plan Check:
$0.00
Per•init Fee:
PME Unit Fee:
$48.00
PME Permit Fee:
$48.00
Construction Tax:
Administrative Fee: (ADMIN
$45.00
Work Without Permit? 0 Yes (F) No
$0.00
Advonced Planning Fcc,,;
Travel Documentation Fee: ITRA VDOC
$48.00
Strong Motion Fee: IBSEISMICR
$0.50
Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC
$1.00
SUBTOTALS:
$190.50
$0.00 TOTAL FEE:
1 $190.50
Revised: 07/02/2015