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15100011 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 11261 CATALINA CT CONTRACTOR:CLAUSEN ELECTRIC INC PERMIT NO: 15100011 OWNER'S NAME: ECKSTEIN JAMES N AND KATHERINE P ET 19970 MCKEAN RD DATE ISSUED: 10/02/2015 OWNER'S PHONE: 2176215573 SAN JOSE,CA 95120 PHONE NO:(408)927-7332 LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL ❑ COMMERCIAL ❑ REMOVE(E)PANEL AND INSTALL(N)125 AMP SERVICE / r/ q c, PANEL License Class C,16 Lic.L# Contractor C l d USr%l ftlYte, >tate ��) 5� 1 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. 1 hereby affirm under penalty of perjury one of the following two declarations: Sq.Ft Floor Area: Valuation:$2400 1 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 APN Number:35621038.00 Occupancy Type: performance of the work for which this permit is issued. y� 2. 1 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 permit is issued. PERMIT EXPIRES IF WORK IS NOT STARTED APPLICANT CERTIFICATION WITHIN 180 DAYS OF PERMIT ISSUANCE OR I certify that I have read this application and state that the above information is 180 DAYS FROM LAST CALLED INSPECTION 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 /Q �/ � ��,�I I D r o Upon the above mentioned property for inspection purposes. (We)agree to save Issued bv: VLA` `'1" " -' Date: QO.JIJ 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 with all non-point source e�ulations per the Cupertino Municipal Code,Section 9.18. RE-ROOFS: r{- C All roofs shall be inspected prior to any roofing material being installed.If a roof is Signature � , _ Date C/ 3 J installed without first obtaining an inspection,1 agree to remove all new materials for T inspection. ❑ 0N1 NER-BUILDER 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 1,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 HAZARDOUS MATERIALS DISCLOSURE sale(Sec.7044,Business&Professions Code) 1 have read the hazardous materials requirements under Chapter 6.95 of the 2 1,as owner of the property,am exclusively contracting with licensed contractors to California Health&Safety Code,Sections 25505,25533,and 25534. 1 will maintain construct the project(Sec.7044,Business&Professions Code). compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health& Safety Code,Section 25532(a)should I store or handle hazardous material. I hereby affirm under penalty of perjury one of the following three declarations: Additionally,should I use equipment or devices which emit hazardous air 1 I have and will maintain a Certificate of Consent to self-insure for Worker's contaminants as defined by the Bay Area Air Quality Management District I will Compensation,as provided for by Section 3700 of the Labor Code,for the maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the performance of the work for which this permit is issued. I lealth&Safety Codh,Sections 25505,25533,and 25534. 2 1 have and will maintain Worker's Compensation Insurance,as provided for by Owner or authorized agent: Section 3700 of the Labor Code,for the performance of the work for which this Date: U �� permit is issued. -- 3 1 certify that in the performance of the work for which this permit is issued,l shall CONSTRUCTION LENDING AGENCY 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 I hereby affirm that there is a construction lending agency for the performance of work's become subject to the Worker's Compensation provisions of the Labor Code,I for which this permit is issued(Sec.3097,Civ C.) must forthwith comply with such provisions or this permit shall be deemed Lender's Name revoked. Lender's Address APPLICANT CERTIFICATION ARCHITECT'S DECLARATION I certify that I have read this application and state that the above information is I understand my plans shall he used as public records. 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 Licensed Professional upon the above mentioned property for inspection purposes.(We)agree to save 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 with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. Signature Date ( GENERAL PERMIT APPLICATION I-I000 ( IM EPp COMMUNITY DEVELOPIJiENT DEPARTMENT-BUILDING DIVISION 10300 TORRE AVENUE-CUPERTINO,CA 95014-3255 (408)777-3228- FAX(408)777-3333- buildinaec ceriino.or CUPERTINO M I ❑PLubs NG ❑MECHANICAL ELECTRICAL ❑MISCELLAXEOL;S PROJrCfADDFESS 11 �WP / / 7la 11&L C� I APN# OWTERNAME , yco I PnN1v ' /7 6s2/—55-7E•I�idIL �IJC- S f(�0'1 G( / STREET ADDRESS �l l o i ( crrY,STATE,z>P CGC FAX • CO>\7.ACT NAMS lu.vll old S- h PHON a c 1-- j E�tpn ��L'E,lr'C,`(/LtJC(d Ce STREET ADDRESS L h J/�i� CITY,STATE,ZIP�� ('9C)Jcll ( /G FAx " /i f (- ) 7 C, ZC ❑ OWN-ER ❑ ORTr'ft•BUIL77t [❑ OW?ERAGL�? ❑ CO>`TIRACTOR ❑COATRACTORAGF2:T ❑ ARC3IEC? ❑ENG4=ER ❑ DEVELOPER ❑ �_NtT.? CONTRACTOR NAa � �J' L1CM:SE NT AQBER LICr"t."SE n-PE� BUS.LIC# / C3/ 7 / COMP.A1.'Y N.A a E-MAIL FAX STREET ADDRESS /G '171) /� / `n �C CITY,STATE P- Z �� /^_� /jJ G �J PHO RCHITECT/ENGI EER NAME / l LICENSE NrafBER I BUS.LIC# ' COIaA.NY NAME E-MAIL I F. STREET ADDRESS CITY,STATE,ZIP PHONE USE OF SFD or DUPLEX ❑ MULTI-F.A\CLY PROJECT LN WC.DLAND ❑ Yas PROTECT IN ❑ YES IS TFL BLDG AN ❑ YES BU=LNG: ❑COMMERCIAL URBEN LN'TERFACE AREA ❑ NO FLOOD ZONE ❑ NO EICF.LZR HOME? ❑ NO DESCRIPTION OF WORK r yv�6'a iz�� , alltlr TOTAL VALUATION: By my signature below,I certify to eachof the folio : I=the property owner or authorized agent to act on the p operty owner's behalf. I have read this application and the information I have provided is o ct. I havekead the Description of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating to building cons ion. I authorize representatives of Cupertino to enter the above-identifi property for inspection purposes. Si ature ofA licant/A ent 0 tJ PP g Date: SUP-F Eb ENTAL INTFORMATIO14 REQUIRED r OiriCKL'� ONLY X711 Ei:=liii:c — L37„isc z J LzF.GE MEPA6scAPP_1011.doc remised 06/21/11 CITY OF CUPERTINO l I FEE ESTIMATOR — BUILDING DIVISION I ADDRESS: 11261 Catalina Ct DATE: 10/02/2015 REVIEWED BY: PAUL APN: 356 21 038 BP#: "VALUATION: 1$2,400 (PERMIT TYPE: Electrical Permit PLAN CHECK TYPE: Alteration /Addition / Repair PRIMARY SFD or Duplex PENTAMATION 1REAP2 USE: PERMIT TYPE: WORK Remove Epanel and Install N 125 Amp Service Panel SCOPE APPLIANCE/ EQUIP TYPE FEE ID QTY UNITS BP FEES Services 1 ERT<200 125 Amps $48 TOTALS: $48.00 Elec. Plan Check0.0 hrs $0.00 Elec. Permit Fee: IEPERMIT LiOther Elec. Insp. LLO hrs 1 $48.00 NOTE: This estimate does not include fees due to other Departments(i.e. Planning,Public Works, Fire,Sanitary Sewer District,School District,etc. . Thesefees are based on the preliminari information available and are only an estimate. Contact the De t or addn 7 info. FEE ITEMS (Fee Resululiun 11-0-53 U.* 7,'1,13) FEE QTY/FEE MISC ITEMS V(PI ( /1(" A 1., `'Igll)l. PC h''� PME Plan Check: $0.00 PME Unit Fee: $48.00 PME Permit Fee: $48.00 Administrative Fee: IADMIN $45.00 Work Without Permit? O Yes 0 No $0.00 1ch'-ance(l Pl(mning h'ees: Travel Documentation Fee: ITRAVDOC $48.00 A Strong Motion Fee: IBSEISAIICR $0.50 Select an Administrative Item 131dil Stds Commission Fee: IBCBSC $1.00 SUBTOTALS: $190.50 $0.00 TOTAL FEE: $190.50 Revised: 07/02/2015