05090190 ;0930
Y OF CUPERTINO 'P
BUILDING DIVISION PERMIT CONTRACT Rb NFOItMATMION
ING ADDRESS: ARINDAM CHAKRABORTY PERMIT ND.OSO9O190
ROSE BLOR'S NAME: PERMITOUEDATE
ARINDAM CHAKRABORTY 8 2005
E:
SANITARY NO. CONTROL NO.
ti
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG EIEC? PLUMB MECH
z 0 0 0 0
Stip LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provision of Chapter 9(commencing Job Description
w10 Section 70M)of Division 3 of the Busineuand Prefesaiuns Cade,and my license is
Imfull fo=And effect REPLACE WINDOWS ( E /1-K T) &
�gb
License Class
Due.Conowtor unTSD 1 PATIO DOOR ( ®
3 ARCHITECTS DECLARATION KL
KK I understand my piano shall W used u public Tae ds
a bi Licensed professional V Z
OWNER-BUILDER DECLARATION V aJoo�
1 beaffirmmby arm that I am exemptm
from chat Ctrac,ar+License Law for Ne L
COO following maven.(Section 70313,Business and Profusion Code:My city or county
1$f which"or.•pmmft W trotted,alter.bnpm re,dem-Her.or repair anY armmumF21)9 fI 9 M t}scne. U ri it
m, pdm W its issuance.sou requires the applicant for such Permit W file Asigned aumment /1`s' � a Valuat I�O O O
-�< thus,he at licensed pursuant to the provision Communes the Comunes Lateran Law(Chapter 9 Sq.Ft. Floor Area U�(.1 A `
sEx�O (commencing with Section 7000)of Division 3 of the Business and ProfeaOns Code)Or
Nat he at exempt Wmbmm and the bull for the alleged exemption.Any violation of
Section 7031.3 by arty applicant for a permit subjects Ne applicant W a civil penalty of APN Number Occupancy Type
not more than five hundred dollars(2500). 35906028 . 00
❑I,As"net of the property.m my employees with wages As their solo compensation,
wildo NewarkandthCarnmure isnot Intended oroRened for sale 7041,Business Required Inspections
and Pmlealons Code:The Consumes License law dans col apply w an owner of q P
property who builds or ire pmms Narcan.and who dace each week hmta3 f or Nmugh h is
own employers,provided Net such Improvements am no,Intended urorterW for sale.if.
however,the buildingor I apmvemm,Ice wld wltWn m yw of mmpleUM.Ne ownef-
Wilder will Nee Ne burden of proving that he did w,Wild or improve for purpos of
Asks.).
EK("wmer of the property,am exclusively conuaning with licensed wmnnon W
construct Ne pm,*1(See.7014.Buslnw and Pmfesslon Code:)The Comsat WYs W-
ceme law docs not apply W an owner of property who builds or improves thereon,and,
who contracts for such pmkms with a contractor(s)Iicenred pursuant W tho C9m arebo S -
License Law.
0 l am exempt under Sec. ,B AaP CCforr this reason
Owner i --/l- -- �•GItC+..:.a 1 Date-5—
W ORKER'3 COMPENSATIONN D�RATIO
I hereby alarm under pensl,y of perjury one of Nc following declarations:
I have and will maintains Canific rf Consent W self-inure fm Wafts-Compcn-
Aslion,As provided for by Section 3700 of the Labor Code,for the performance of use
work for which that permit is issued.
❑1 have and will msinsain Workers Compensation Imuran¢,as required by Section
3700 of the Labor Code.for the PeRormma of Ne A mk fmwhich this penult at issmN
My Workers CompewBon Wunnm unite and Policy number am:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
miusectimn need nut Mcompleted lithe pcfmlt N farenc hundfeddallm(SI W)
or less.)
I«ni(y that fn the Mr...of the wmk for which this permit is issued,I shall not
employ any person in my manners u te become-111-1 to the Worker'Ounramudm
Laws of Califo rr}Dem —
Applfcant�
NOTICE TO APPLICANT:If.after making Nis CeNnam of Emmpti n.you should
become Subject W UW Woftes Campenatim provisions of the Labor Code you an=
OO forthwith comply with such provisions or this permit Nall W derment mocked.
zCONSTRUCTION LENDING AGENCY
(..,,T I kremby arrom Nat Nero Is construction lending agency I.ft Peffeacromeof
a�E tho wutk fur which this permit 4 Issued(Sec 3097,Civ,C.)
W Q Lenders Name
.7 z Lenders Add.
U O I certify Na,I have rad Nis Application and cute that the above Inform W on is .
correct.l gree to comply with all city and county ordinancat and state laws mlating to
0 building convection.And hereby auNmbe repm+entnha Of this City 10 enter upon ft
Ibl above-mentioned property fm impaction purposes
6r (We)agree W save,indemnify and keep harmless the City of Cupertino against
n,t to liabilities,judgmmu.costs and expense which may in my way aaxuc again,aid City
U Z in cowquence of the Irandng of this Perron, q
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: a Date
SOU?Yub<UTATIDNS.
Re-roofs
SignatureplinnVCaARDOU Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
applicant m fMuni building e.Chapter
more Orhandlethe Health a materW
u dethe 32(x)?Cupertino Municipal Code.Chapter 9.@,arW Ism Health and Safety
odess3a(a)7 / All roofs shall be inspected prior to any roofing material being installed.
@NO
Will Air contaminants
or ntsA Wilding byoccupant Bay
eyulir Quordeviceswhich
If a roof is installed without first obtaining an inspection,I agree to remove
h air conumifunu u defined by Ute Bay Ara Air Quality Management all new materials for inspection.
m
' u
I have mad site huafaonamareratatregniremenu under Clupier 6.95of theCafmr-
niellce0b8 Safetycode.Sendmu25505.25533 and 25534.1anarnund th all'ths Wilding
doss no,currently haw a moan,that it 4 my msponslbility W coolly tbe occupant or the
requirements which ron,Ix,MCI Poor WiaammafacwRamafoapany. Signature of Applicant Date
6-4=l'"cam,, 7-'�"'� All roof coverings to be Class"B" or better
Owner or authoriced agent Dom
Community Development
1300 Torre Avenue
SM
Cupertino CA 95014
Telephone(408) 777-3228
CITY OF Fax(408)777-3333
�UPERTINO
Building Department
JOB ADDRESS: q 5 12&SE r3�bsy,ri �K PERMIT #
CuW (rR-TiND3 12 4d119G
OWNER'S NAME: ,J Nip" (2 VA-I<,e^ '30Q-rlf PHONE #
GENERAL CONTRACTOR: pw N rfe ujj- t)y5g FAX#
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following information
60 SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
x�F Cabinets &Millwork
U� Cement Finishing
Electrical
Excavation
Fencing
Flooring: Carpeting
Linoleum/ Wood
Glass/ Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Owner/Contractor Signature Date
._.,.. a�.,t�;v'>'G'aSa...,rLaW4�i— .._. -k��x'yxfx. .......... ...... . ...... .. ..........
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P EP 2.8 2005
�bE COPY
,�o(d yes'S C EFA�c2sv3oa
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930 oj� l3GossoM,
12
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CUPE2Tf NO
CA 9'So IL�
P�, � <pog�g46� 2s�76
6.
CUPERTINO Y
Assessor's Parcel Number:
Name of owner. A e r 1.1 D" e a A T Y
Project address., 930 0'�(3SE GLoSso-M D)Z
Contact person. A K I N DPIA C WIN RRt3 f Phone. 4 Q G 2-5-7 0
Fax.
Net square footage of lot.
Existin Proposed
Square footage: First floor:
Second floor:
Garage:
TOTAL:
• Are there at least two 10 foot by 20 foot clear spaces inside the garage? Y N
Is privacy protection planting required for the project? Y N
On what floor(s) is work being done? `
r (ac¢ 2 - r3ccf� oo �3 t vcforJ , I — dLi 4cC azM Jl Y �1cJZJ
Brief description of work.
.Code editions:2001 CBC N)2001 CFC (Y -N)2001 CMC (Y-N)
2001 CPC (Y -N)2001 NEC (Y - N)
C&Vnpl-j- Abrn n C 6B� S 1�. otcv d 1
Effective 11/1/02
Plan Review Process Work Book Page-8-Revised 4/28/04
OWNER-BUILDER VERIFICATION
1. (Check one) I or my immediate family (parent,spouse or child) will perform:
A. _ All the work authorized by this permit
B. _ A portion of the work
C. ✓None of the work
If B or C is checked,complete 2 or 3 below.
Z A state licensed contractor will be hired to do:
A. ✓ All of the work
B. A portion of the work (complete section below)
Contractor Address/City Phone # State License # Type of work to
be Performed
Home bppoT De—A11a P7-I U 770 - z
• 3. _ I will utilize unlicensed person(s) other than my immediate family to perform all or
portions of the authorized work. I understand that I may be an employer (see reverse side). A
Certificate of Insurance covering workers' compensation must be on file at the City of
Cupertino Building Department office.
Persor/Firm Address/City . Phone Number Type of work to be
erformed
.....................................................................................................................................................................................
I declare under penalty of perjury that the above is true and correct. I have read and understand the
Owner-Builder Information(reverse side).
Property Owner's Signature: \ l��r innofpn G� G✓�c. �1 aC j� Date:
Job Address: 930 k F tikl asco A De Permit#
Cu0jC- a-r tNo; CA q5-o t4
Any changes to the information provided on this form shall be submitted to the City of Cupertino Build
Department.
City of Cupertino Building Department
OCIF 10300 Torre Avenue,
C U D C Q'T'I NO Phone: (408)777-32�2gg��
Dear Property Owner:
An application for a building permit has been submitted in your name listing yourself as the builder of
the property improvements specified.
For your protection you should be aware that as owner-builder you are the responsible party of record
on such a permit Building permits are not required to be signed by property owners unless they are
personally performing their own work. If your work is being performed by someone other than yourself,you
may protect yourself from possible liability if that person applies for the proper permit in his or her name.
Contractors are required by law to be licensed and bonded by the State of California and to have a
business license from the city or county. They are also required by law to put their license number on all
permits for which they apply.
If you plan to do your own work,with the exception of various trades that you plan to subcontract,you
should be aware of the following information for your benefit and protection:
If you employ or otherwise engage any persons other than your immediate family, and the work
(including materials and other costs)is$200 or more for the entire project, and such persons are not licensed as
contractors or subcontractors, then you may be an employer.
If you are an employer,you must register with the state and federal government as an employer and
you are subject to several obligations including state and federal income tax withholding,federal social
security taxes,workers' compensation insurance,disability insurance costs,and unemployment compensation*
contributions.
There may be financial risks for you if you do not carry out these obligations, and these risks are
especially serious with respect to workers' compensation insurance.
For more specific information about your obligations under federal law,contact the Internal Revenue
Service (and,if you wish,the U.S. Small Business Administration). For more specific information about your
obligations under state law,contact the Department of Benefit Payments and the Division of Industrial
Accidents.
If the structure is intended for sale,property owners who are not licensed contractors are allowed to
perform their work personally or through their own employees,without a licensed contractor or
subcontractor, only under limited conditions.
A frequent practice of unlicensed persons professing to be contractors is to secure an owner-builder
building permit,erroneously implying that the property owner is providing his or her own labor and material
personally. Building permits are not required to be signed by property owners unless they are performing
their own work personally.
Information about licensed contractors may be obtained by contacting the Contractors'State License
Board in your community or at 1020 N Street,Sacramento,California 95814.
Please complete and return the enclosed owner-builder verification form so that we can confirm that
you are aware of these matters. The building permit will not be issued until the verification is returned.
Very truly yours,
Building Department,
City of Cupertino
Printed on Recycled Paper
CITY OF CUPERTINO o s� l 9
011TY0 PERMIT APPLICATION FORM C
CUPEII,TINO
N# �— j � U . Date:
Building Address: Mailing Address (if different from building address):
30 ,26b55o Ll D P, 0 P):=e h1 a ( A- -JsO 14
Owner's Name: Phone#: 409 —44 6 -2$7 d
A-QINberm CH - Qi A 0R T"
Contractor: e License#:
C�c.� (map, Gvildey
Contact: Phone: Cupertino Business License#:
Fax:
Building Permit Info: Pl-eo( Rco w w i v c(b CJs. I - ICi FG�c,1 v11 ozJ � .
1 — �A-T10 0012
Bldg ❑ Elect ❑ Plumb ❑ Mech ❑
Job Description:
Residential ❑ Commercial ❑
Sq.Ft. Floor Area: q:Ft.:
Cost of Project: QD o� Occupancy Group:
Type of Construction: Please check this box if the project is a
second-story addition: ❑
ro'ect Size: Standard a Laze ❑ Major ❑
Quantity Fee ID Fee Description Fee Group
BAPPLOTHER Other Appliances MECHANICAL
BBOILERI Boiler<= 100,000 Btu MECHANICAL
BBOILER2 Boiler> 100K to 500K Btu MECHANICAL
BBOILER3 Boiler> 500K to 1M Btu MECHANICAL
BBOILER4 Boiler> 1M to 1.75 M Btu MECHANICAL
BBOILERS Boiler> 1.75M Btu MECHANICAL
BCONSTAX Construction Tax BUILDING
BCONSTAX Ind/Off/Comm/Quasi BUILDING
BCONSTAXBQ Con. Tax for BQ Zone BUILDING
BCONSTAXH Hotel and Motel BUILDING
BCONSTAXR Constax—Resi/Mobile BUILDING
BELEC1000 Elec 600V <= 1000A ELECTRICAL
BELEC1001 Elec 600V> 1000A ELECTRICAL
BELEC200 Elec Svcs 600V<=200A ELECTRICAL
BENERGY Energy BUILDING
BENERGYADD Energy Add Multi BUILDING
BINVESTIGA Investigation fee BUILDING
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CITY OF CUPERTINO
cuPEr�Tnvo PERMIT APPLICATION FORM
uanti Fee ID Fee Description Fee Group
BMISCELL Miscellaneous Fee BUILDING
BMITIGATC Comm. Housing Mit. Fee BUILDING
BNUCOMME New Comm Electric ELECTRICAL
BNUCOMMM New Comm Mechanical MECHANICAL
BNUCOMMP New Comm Plumb PLUMBING
BOVERTRAE Inspection Overtime BUILDING
BPBACKFLOW Atmospheric Vacuum - . PLUMBING
BPCESSPOOL Cesspool PLUMBING
BPERMFEE Bldg Permit Fees BUILDING
BPFIXTURE Pblg Fixture PLUMBING
BPGAS Gas Piping System Fee PLUMBING
BPINTERCEP Ind Waste Interceptor PLUMBING
BPLANCHK Plan Check Fee BUILDING
BPLANCKADD Plan Check Add Multi BUILDING
BPLANCKREP Plan Check Repeat Fee BUILDING
BPRE PIPE Re i e Of Fixtures PLUMBING
BPSEWAGE. Sewage Disposal PLUMBING
BPSEWER Sewers PLUMBING
BPSPRINK Lawn S rinklerBackflo PLUMBING
BPSTORM StomvRain Water PLUMBING
BPTRAP Kitchen Trap PLUMBING
BPVENT Alt of Drain &Vent PLUMBING
BPWATER InstalUAlter Water Pie PLUMBING
BPWHEATER Water HeaterNent PLUMBING
BPWSVCS Main Water Service PLUMBING
BREINSPECT Reinspection Fee BUILDING
BREMACOVER A/C Unit> 10,000 cfin MECHANICAL
BREMAIRHAN A/C Units<= 10,000 cfin MECHANICAL
BREMAPPLI Appliance Install MECHANICAL
BREMBUSWAY Remodel Busways ELECTRICAL
BREMFIXT Lighting Fixtures ELECTRICAL
BRENTURN Relocation of Furnace MECHANICAL
BREMFURNOV Relo Furnace> l OK btu MECHANICAL
BREMHEAT Heater Installation MECHANICAL
BREMINHOOD Installation of Hood MECHANICAL
BREMMISC Misc Apparatus ELECTRICAL
BREMNRAPP Rem Non-Res Appliance ELECTRICAL
BREMPOLE Pole/Platform Fixture ELECTRICAL
BREMPOWER Power Device/Apparatus ELECTRICAL
BREMRECEPT Rcpt], Switch & Outlets ELECTRICAL
BREMRELOCA Relocation of Hood MECHANICAL
BREMREPALT Repair/Alter Heating MECHANICAL
BREMRESAPP Remodel Res Appliance ELECTRICAL
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CITY OF CUPERTINO
CUPEf�TINO PERMIT APPLICATION FORM
QuantityFee ID Fee Description Fee Group
BREMSIGNAD Rmdl Signs Add Branch ELECTRICAL
BREMSIGNS Remodel Signs, Marquee ELECTRICAL
BREEMTHEATR Theatrical Lighting Fix ELECTRICAL
BREMVENFAN Vent Fan Single Duct MECHANICAL
BREMVENSYS Ventilation Systems MECHANICAL
BSCBLVD Scb Specific Plan BUILDING
BSEISMICOM Seismic Commercial BUILDING
BSEISMICRE Seismic Fee Res BUILDING
BSPECIAL Special Inspection BUILDING
BSWIM Swimming Pool BUILDING
BTEMP Temporary Power ELECTRICAL
BTEMPPERM Temporary Bldg Permit BUILDING
BTEMPSVCS Temp Dist Svcs ELECTRICAL
BUSLIC Business License BUILDING
ELECTRIC Electrical sq foot ELECTRICAL
EPERMITFEE Elec Permit Issuance ELECTRICAL
MPERMFEE Mechanicals . foot MECHANICAL
MPERMITFEE Mech Permit Issuance MECHANICAL
PPERMITFEE Plumbing Permit Issue PLUMBING
PPLBG Plumbing Fee sq foot PLUMBING
PLLONGRNGC Planning LR Comme/Multi-Fam PLANNING
PLLONGRNGR Planning Long Range Residential PLANNING
ZADDCHG Address Chane BUILDING
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