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15120147Q CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 20238 NORTHWEST SQ CONTRACTOR: MIKE COUNSIL PERMIT NO: 15120147 PLUMBING INC OWNER'S NAME: BROWN ANN L 1 a e_,e, 1915 O'TOOLE WAY DATE ISSUED: 12/16/2015 OWNER'S PHONE: 4089963899 SAN JOSE, CA 95131 PHONE NO: (408) 272-4900 LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL COMMERCIAL 17n UPGRADE SUB -PANEL TO 100 AMP License Class C % ic. 4 05,6 3 Z � Contractor Date �l2 that I am licensed under the provisions of Chapter 9 I hereby af, hap (commenci g 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: $2000 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: 31639047.00 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 DAYS FROM LAST CALLED 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 Issued by: Date: l' 1 granting of this permit. Additionally, the applicant understands and will comply with all non -point source regulations per the Cupertino Municipal Code, Section RE -ROOFS: 9.18. 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) 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. 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 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, 2 33, and 25534. Section 3700 of the Labor Code, for the performance of the work for which this 9 Owner or authorized agent: Datef .4 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 4 CUPERT1N0- GENERAL PERMIT APPLICATION COMMUNITY DEVELOPMIENT DEPARTMENT • BUILDING DIVISION 10300 T ORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 - FAX (4,08) 777-3333 • buildinOO cuoertino.org VELEC=CA-L .1-si02OIq'-❑ Pi'umm e ElI EcKkxTiCAL. ❑ 1,611SCELLAINMEOUS tVFPl1j'isCApp_7011.doc remised 06121/11 PROJECT ADDPISS �^ / 2N 111 f _ ZdZ ` � I b Otb -R X.m' STREET ADDRESS I CITY, STA E, ZIP FAX � :2 41222 CO?\TACT �_ J P�� H0 E- '-IIL STRErTaDDicE S ( CITY�i'�,/Z!P I FAX - /v� ❑ OF'? _R ❑ OP,'I.'ER-BUILDER ❑ OFrN�t AGENT ❑ COISP.ACTOR ❑ COKI- ACTOR AGS T ❑ ARC=:ITCT ❑ ENGII =_R ❑ DEQ LLOP-=k ❑ TaKkXTT CONTR TRI AJ,B I LICENSE NU BER I LICENSE TYPE I BUS. LIC CO JPS7Y '.kl✓HI E-N_�rL a FAX mc, I J-TE,ZIP STRETAT�DRE S j CI ARCHITECTrNGNER T'Al2x LICENSE? TUA,B' I BUS. LIC COlJ3FrvY ,?EIJF E_IJiAy I FAX STREET ADDRESS I CITY, STATE, ZIP I PHONE USE OF orDL'PI.F.X ❑ I✓,IiLTI-FAhC1-Y . PROTECT IN' R'ILDLEND ❑ YES PROTECT LN ❑ YES IS TIM BLDG AN ❑ YPS BU-ILDE^G:❑COh9,1EFCIti I JR3�NL^TR ACL AREA ❑ NO FLOOD ZOMBE ❑ NO MCFLERHOMI-E? EJ NO D SCEPTIONT OF 7YORK 100 a �. ' TOTALS?A.LUATION ��jj��/ RECFIS�DBl r 1` By my signature below, I certify to each of the following: I am the property owner or authorized agent to act on the properrrty owner's behalf.- a e 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 wi applicable local ordinances and state laws relatisrg to building const ion. I authorize representatives of Cupertino to enter the above -identified prop-. y for inspec ion purposes. Signature ofApplicant/."-.gent: Date; UPPLE?\�NTAI NI-ORv_rATI0NT REQULRED ',_:. OFFSCEUSEO�LI::.:j:: on a v> O�'B7 . TiiE 1.6 91--.-';' . �. x,n, Z 4 2 +: � < 3 '❑ ��RG$ � � � r._:z� ��.�'n �.�. ter. ,,� tVFPl1j'isCApp_7011.doc remised 06121/11 CITY OF CUPERTINO FEE ESTIMATOR — BUILDING DIVISION ADDRESS: 20238 Northwest Sq FEE ID DATE: 12/16/2015 REVIEWED BY: Phuong APN: 316 39 047 BP#: *VALUATION: 1$2,000 *PERMIT TYPE: Electrical Permit 1 ERT<200 PLAN CHECK TYPE: Alteration / Addition / Repair PRIMARY SFD or Duplex USE: Amps PENTAMATION 1 REAP2 PERMIT TYPE: WORK U grade sub -panel to 100 amp SCOPE APPLIANCE EQUIP TYPE FEE ID (-'heck QTY UNITS BP FEES Elec. Permit Fee: IEPEPMIT Services 1 ERT<200 Other Elec. Insp. 1 0.0 1 hrs $48.00 100 Amps $48, PME Unit Fee: $48.00 PME Permit Fee: $48.00 F Administrative Fee: ]ADMIN $45.00 Work Without Permit? 0 Yes (F) No $0.00 TOTALS: 'A Travel Documentation Fee: ]TRAKDOC $48.00 Strong Motion Fee: I BSEISMICR NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School District etc.). These fees are based on the vrelintinary information available and are onlv an estintate. Contact the Dept for addh 'I info. FEE ITEMS (Fee Resolution .1.1-053 Lff 7,7113 FEE (-'heck Elec. Plan Check 10.0 1 hrs $0.00 Fee, J, F Elec. Permit Fee: IEPEPMIT Other Elec. Insp. 1 0.0 1 hrs $48.00 Ale""Ifi. Phanb. $0.00 NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School District etc.). These fees are based on the vrelintinary information available and are onlv an estintate. Contact the Dept for addh 'I info. FEE ITEMS (Fee Resolution .1.1-053 Lff 7,7113 FEE QTY/FEE7 MISC ITEMS PME Plan Check: $0.00 PME Unit Fee: $48.00 PME Permit Fee: $48.00 F Administrative Fee: ]ADMIN $45.00 Work Without Permit? 0 Yes (F) No $0.00 r. 'A Travel Documentation Fee: ]TRAKDOC $48.00 Strong Motion Fee: I BSEISMICR $0.50 Select an Administrative Item Bldgf Stds Commission Fee: IBCBSC $1.001 SUBTOTALS: $190.501 $0.00 TOTAL FEE: $190.50 Revised: 10/01/2015