15060192 (2) CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 18860 LOREE AVE CONTRACTOR: h h\1 PERMIT NO: 15060192
n
OWNER'S NAME: CELIA LA RIVIERE LEWS AVE DATE ISSUED:06/30/2015
OWNER'S PHONE: 4086630825 8NNN VPA_F_4
CA qM PHONE NO:
LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL ❑ COMMERCIAL
�SZ UPGRADE EXISTING 100 AMP PANEL TO A NEW 125 AMP
License Class G—t0 Lic.# PANEL
Contractor '0'^1C�y4A C.b"Z_IX.tC Date-30-1 15�
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:$1800
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:37515017.00 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 INSPE TI
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 byl {— V� Date:
with all non-point source regulations 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
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)
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. 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 25505,25533,and 25534.
Section 3700 of the Labor Code,for the performance of the work for which this
Owner or authorized agent: Date: -3o-Ir
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
.._._................_.. .....
GENERAL PERMIT APPLICATIONjqMEP
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COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING VIS N
10300 TORRE AVENUE• CUPERTINO, CA 95014-3255 MISC
CUPERTINO (408)777-3228• FAX(408)777-3333• buildingC@cupert!no.org
❑PLUMBING ❑MECHANICAL ZELECTPUCAL ❑MISCELLANEOUS
PROJECT ADDRESS APN n `�q
1% (,o Loa_ Nva
5 150/3--
OV✓NERNAME PHONE 661-,.,�_ - E-MAIL
6.41 �Z
STREET ADDRESSpp CITY, STATE,ZIP FAX
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CONTACT NAME I _ PHONE/ pprr1^� E-MAIL
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STREET ADDRESS Qp :�j CITY,STATE, ZIP FAX
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❑ OWNER ❑ OR'NER-BUILDER ❑ OWNNR AGENT CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR ITTAD�E LICENSE NUMBER LICENSE TYPE BUS.LIC#
l&Z I Com- t
COMPANY NAME E-MAIL FAX
STREET ADDRESSCITY,STATE,ZIP PHONE
��'3 S S-4114-(_C eel, 9C-108(Cl (,�a vZ3-8�8�
ARCHITECT/ENGD\TER NAME LICENSE NUMBER BUS.LIC n
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OFSFD or DUPLEX ElMULTI-FAMILY PROJECT IN WILDLAND ❑ YES PROJECT IN ❑ YES IS THE BLDG AN YES
BUII DL*1G: ❑COMMERCIAL URBAN INTERFACE AREA 0 FLOOD ZONEO EICHLER HOME? ❑ NO
DESCRIPTION OF WORK _
A.,AP ` ';- Z n M
TOTAL VALUATION: 4rC'>,) .Gp RECEIVE➢BY�2
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 ding cons ction. I authorize representatives of Cupertino to enter the above-identified property for inspection purposes.
Signature of Applicant/Agent: Date:
SUPPLEMENTAL I NTORMATION REQUIRED
O _C"'TOW Vii;
X9WEIE CQ,iJIsT�Eft
kfEPAIiscApp_201 1.doc revised 06/21/11
CITY OF CUPERTINO ICTWIC '
FEE ESTIMATOR — BUILDING DIVISION
ADDRESS: 18860 Loree Ave DATE: 06/29/2015 REVIEWED BY: Paul
APN: 375 15 017 BP#: 'VALUATION: $1,800
A 0
YPERMIT TYPE: Electrical Permit PLAN CHECK TYPE: Alteration /Addition / Repair
PRIMARY SFD or Duplex PENTAMATION 1 REAP2
USE: PERMIT TYPE:
WORK U grade exisitnq 100 Amp panel to a new 125 Amp panel
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Services 1 ERT<200 125 Amps $48
TOTALS: $48.00
,31ec:h. Plan Check Phuuh. Plan Check Elec. Plan Check 0.0 1 hrs $0.00
tlech M-oili Plumb, Permit Fe" Elec.Permit Fee: IEPERMIT
Other Mech. Ins). Other Plumb Insp. Li Other Elec.Insp. LLO
hrs $48.00
ch. /nal?. Fee: Phuub. 117sp. Fcc [lec.Insp. Fee:
NOTE: This estimate does not include fees due to other Departments(i.e. Planning,Public Works, Fire,Sanitary Sewer District,School
District,eta). Thesefees are based on the prelimina information available and are only an estimate. Contact the De t or addn'l info.
FEE ITEMS (Fee Resolution 11-053 Eff.' 7%1/13) FEE QTY/FEE-7 MISC ITEMS
PME Plan Check: $0.00
Permit l�t:
S111yd' Insp Fee
PME Unit Fee: $48.00
PME Permit Fee: $48.00
Construction Tax.
Administrative Fee: IADMIN $45.00
Work Without Permit? Yes (F) No $0.00
Travel Documentation Fee: I TRA VDOC $48.00
Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item
Bldp-Stds Commission Fee: IBCBSC $1.00
SUBTOTALS: $190.50 $0.00 TOTAL FEE: $190.50
Revised: 05/07/2015