15050029 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 907 BLAZINGWOOD AVE CONTRACTOR:TRAN JUNIOR GENERAL PERMIT NO: 15050029
CONSTRUCTION
OWNER'S NAME: O'KEEFE MICK AND BHANDAL KAMAL 728 DAKOTA DR DATE ISSUED:05/06/2015
OWNER'S PHONE: 6505764079 SAN JOSE,CA 95111 PHONE NO:(408)829-1777
LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL E] COMMERCIAL
C� INSTALL TEMPORARY POWER
License Class_,_ L I l 1` _ Lic.
Contractor Date
Date F
I hereby affirm that I am licensed under the 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
performance of the work for which this permit is issued. Sq.Ft Floor Area: Valuation:$250
II 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:36920013.00 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 O + T 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 D S F AS LLED 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 S }
granting of this permit. Additionally,the applicant understands and will comply ate:
b
with all non-point source regulations per the Cupertino Municipal Code,Section
9 18.
_ -ROOFS:
Signature Dale f's 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)
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 534.
Section 3700 of the Labor Code,for the performance of the work for which this Owner or au ized agent: Date-+
permit is issued.
1 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
GENERAL PERMIT APPLICATION 00" MEP
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255
MISC(408) 777-3228• FAX(408)777-3333•building a(Dcupertino.orq \
CUPERTINO
❑PLUMBING [:]MECHANICAL ❑ELECTRICAL / ❑MISCELLANEOUS
PROTECT ADDRESS q2 _ APN# �Z�./_ rJ n b 1 -3
% l d(J (�V
OWNER NAME /
PHONE E-MAIL
STREET ADDRESS CITY, STATE,ZIP FAX
CONTACT NAME PHONE _ E-MAIL
Ell 7
STREET ADDRESS CITY,STATE,ZIP FAX
❑ OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT CONTRACTOR ❑CONT
,ACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT
CONTRACTOR NAME LICENSMBER LICENSE TYPE BUS.LIC#
(�
E0'off
COMPANY NAME CUp E-MAIL FAX
STREET ADDRESS CITY,STATE,Z PHONE
ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC#
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF ❑SFD or DUPLEX ❑ MULTI-FAMILY PROJECT IN WILDLAND ❑ YES PROJECT IN El YES IS THE BLDG AN ❑YES
BUILDING: ❑COMMERCIAL URBAN INTERFACE AREA ❑ NO FLOOD ZONE El NO EICHLERHOME? [3 NO
DESCRIPTION OF WORK I
MA-
TOTAL VALUATION ria e Iy i
g; r s
By my signature below,I certify to each of the following: I am the property owner or aut ed agentITact on the property er' alf. I have read this
f Work and veri It is accurate. I comply with all applicable local
application and the information I have provided is correct. I h fy
ordinances and state laws relati uilding const, n. I authorize representatives of Cupertino to enter the above-identified property for inspection purposes.
SignatureofAppl� Agent: Date:
0c nil,
I W + c s zw
PPLEMENTAL INFORMATION REQUIRED
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MEPMiscApp_2011.doc revised 06/21/11
CITY OF CUPERTINO
FEE ESTIMATOR—BUILDING DIVISION
ADDRESS: 907 BLAZINGWOOD DATE: 05/06/2015 REVIEWED BY: MELISSA
APN: 369 20 013 BP#: 'VALUATION: $250
*PERMIT TYPE: Electrical Permit PLAN CHECK TYPE: Alteration /Addition/ Repair
PRIMARY SFD or Du lex PENTAMATION 1REAP14
USE: p PERMIT TYPE:
WORK INSTALL TEMPORARY POWER
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Temporary Power 1ERT<200 100 Amps $48
TOTALS: $48.00 "
a.
ler; f'f,>r�Cres b P-ujf,,f> P;'(11r("laecic Elec.Plan Check 0.0 hrs $0.00
�t8rki.1'err,=sri I i,,,, 11h1w.b.Perrrl Fee Elec.Permit Fee: IEPERMIT
r Other Elec.Insp. E7rs $48.00
Omer R tech- lrrs other r/w"b Mst:.
1abFc :
rr/.Irsf;.1:
NOTE:This estimate does not include fees due to other Departments(i.e.Planning,Public Works,Fire,Sanitary Sewer District,School
District,eta). These fees are based on the prelinddna information available and are only an estimate. Contact the Dept-for addn'l info.
FEE ITEMS (Fee Resolution 1.1-053.Eff. 7/1/13) FEE QTY/FEE MISC ITEMS
Plan("'heek.Fee:
PME Plan Check: $0.00
/'Cr77Zt{.1'L'.E::
;S'l,rzpl. :nsp Fee
PME Unit Fee: $48.00
PME Permit Fee: $48.00 -F-71
(.Codi-11clioii RTv: -
Administrative Fee: IADMIN $45.00
Work Without Permit? 0 Yes (F) No $0.00
Advanced.f 1011YO19.l''ees:
Travel Documentation Fee: ITRAVDOC $48.00
Strom Motion Fee: IBSEISMICR $0.50 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $1.00
SUBTOTALS,,., $190.50 $0.00 _ TOTAL:FEE $190.50
Revised: 04/01/2015