08110001 CITY OF CUPERTINO "'
BUILDING DIVISION PERMIT CCl1Y'TRACTQRINFORMtTION'
BUILDING ADDRESS: PERMITNO.
11280 BUBB RD ATN CONSTRUCTION INC. OR110001
OWNER'S NAME: PERMrr ISSUE DATE
ONE: CONTROL NO.
(408) 9.66-6541
ARCH=IENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
uaaLICENSEDCON ACTOR'S DECLARATION Job Description
mC I hemby xMmo that I wn Ikcased ander provisions of Chapter 9(Comencin
mg P
u with Socdm 70M)of Division 3ofthe Buvoeas and Profession Code.and my licenxa
U
lerdlfomaandeffccs RELOCT ELECT PANEL UNDERGROUND; UPGRADE 100KVA
P Z License Clue Lk.t
=moo Dam Contractor T0200KVA
ARCH17ECfS DECLARATION
C 1 undersand my plana Nall he used u public is ards
Dieu
g G Licensed Professions!
3 OWNER-BUIUER DECLARATION
if I hereby alRnn thst I am exempt foam the Convano's Ucenso Law for the
00 (ollowing meson.(Section 7(31.5,Business and Professions Code:Any city or County
u$r which requires a permit m consvuct,atm,.improve,do noHm.or repoir try saucture
i< prior m is issuance.also requires the applicant farsuch permit m file a signed summent
—
Egs tharWvlicensedpurmantCdocprovisionsOftheConuactr'sUccamLaw(aRloct9 Sq.Ft.Floor Area Valuation
YF$ (commencing with Sceuon 70D0)of Division 3 of thin Busmen and Professions Code)or 5000
y that he u excmpt the¢frum and the hues for the Wlcgcd eaempuan.Any violation of
Section 7031.3 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
not mom than five handled dollen(5500). 36206047 . 00
❑I,u Dourer of dC pmprny,m my emplvycu wIdo wage u thev sok campensadou,
will do doewook,and theaWaam is not imm�ded,ocull for sale(Sec 70th,Business
and Profmadons Cade:riaCona.emra Lieense Law dea mut appy m an owner of Required Inspections
property who Wilda orirepmves thereon,andwha dvesruch work hlmaclfm through his
own employs,provided that such improvements art notinmMed ora@red fm sale.If.
hrwews,the Wilding or improwmmt is sold within arm year edcompleum,the awna-
Wuda will haw dem Wrkn of proving wt has did Out Wild or Improve fm purpose or
sskJ
❑I,u Owner of dm property am exclusively conuacting with liaised Contractors m
mestruct the project(Sac.70x4,Business and P fczSi s Cade:)The Cmuacmr's U-
.Law doss not appy of an.Of property wW Wilds or improves Nemon,and.
who contracts for such projects with a CoouaaaRs)licensed pursuant in the Convanor's
Limens,Law.
❑I am aaopt under See .B&PC���fm�ths
h�i))re�s.f
�wn
Owner y
Dam —
WORKERS COMPENSATION DECLARATION �s iv
1 hrmby Inde under Penalty of perjury ane of the following da3aoaums:
Wmi haw and will msinain•CertiOexm of Consent toselyiname fm Workers Comprn
,u provided fm by Senior 3700 Of the Labor Code,for this performance of Ibe �
fm which this permit u issued.
❑1 have and will maintain Workers Compensation Insunna,u wired by Secuou
3700 of dm ltWr Code.fm the performance of the work for which Nis permit is issued. '
My Words Compensation Insurmcc carrier and Policy number am: -
Carricrt Policy No.:
CERTIFICATE OF EKEM MON FROM WORKERS
COMPENSATION INSURANCE
Cruz section nand Out be completed if the Permit is forme hundred dollars(SI00)
or less)
I ani(v,that in the performance Of that work for which this Permit is issued.I shall not
employ any person in any manner psi mV-a syYjecl m the WnW Compcvauon
Laws of Califama. I L/ {{ OO t){{
Applicant Isgienda —
NGTICE TOAPPLICANT.IL after g this CcnoRam Of Exemption.you should
become subiea in the Worker's Compensation provisions of um Labor Code,you most
.,z fOMwith comply with such provieinru or this permit iliall he deemed rovokcd.
z^ CONSrRUcnON LENDING AGENCY
[—i I Wreby affirm Wt there is a consoainn Coding agency for the performance of
a the work for which this permit Is issued(Ss,.3097,Civ.C.)
Q lender's Name
=z LcMeh Address
U 0 1 certify taut I haw read this AFFIlmd(m and enm doll the above WN IUM is
W P coma I agocc in comply with JI city and comety ordinances and aside Ins rthung to
0Wilding coramdon,and hereby authorise repoesmudws of this city m enter upon the
W ushow-mendmned property for inspeWm purposes
" G (We)agree as taw,indemnify tad keep humks the City of Cupertino agsiut
liabilities.judgments.emu and upeues which may in my way ocean against said City
U z in cOmegeerme of the graining of this permiL J/
^' APPLICANT UNDERSTANPI)AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
OUR REGUTA f S. I/ _ w* 'k Re-roofs
Signalereof AppdcantlComraaor/`)'
HAZARDOUS MA7FJtlAIS DISCLOSURE Type of Roof
Will theapplicant or factum Wilding occupant stale or bandk ha seli material
as deDmd by the Cupenim Municipal .Chapter 9.13.and the Haulth and Safety
Code.Semonu532(a)T All roofs shall be inspected prior to any roofing material being installed.
❑Yu o
Will the applicant or future Wilding Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
ii hansNou oir Muniouna u d fined by ftBay Arm Air Quality Management all new materials for inspection.
N CIT
Yes U
1 have level the houudo a mamrialsrequiremcnls under Chapmr6.95 ofum Califon,
niaHmith&Safmy Code,Scetions 25505.25533 and 25534.1 mdeaund thutifthc Wilding "
docs not currently haw a moan.Nu it is pdaeibiiiiy to notify im dmupsm of im
mgmmmena which m wmet prior to illa,ofa Casifmam or Occupancy. Signature of Applicant Date
All roof coverings to be Class'%"or better
Owner or authornmd agent Dam
CITY OF CUPERTINO
• 4 ITEMS OF 4 PERMIT RECEIPT OPERATOR: pdtg
COPY # 1
Sec : Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 36206047 . 00
DATE ISSUED. . . . . . . : 11/03/2008
RECEIPT #. . . . . . . . . : BS000006525'
REFERENCE ID # . . . : 08110001
SITE ADDRESS . . . . . : 11280 BUBB RD
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : RAO KOTA
ADDRESS . . . . . . . . . . : 11280 BUBB RD
CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-4979
RECEIVED FROM . . . . : RAO KOTA
CONTRACTOR NHA TRAN LIC # 30471
COMPANY ATN CONSTRUCTION INC
ADDRESS . . . . . . . . . . : 2720 RUBY AVE
CITY/STATE/ZIP . . . : SAN JOSE, CA 95148
TELEPHONE . . . . . . . . : (408) 966-6541
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- - ------- ----------
1BSEISMICR VALUATION 5, 000 . 00 0 . 50 0 . 00 0 . 50 0 . 00
1EPERMITFE FLAT RATE 1 . 00 40 . 79 0 . 00 40 .79 0 . 00
1ERT>1K UNITS 1. 00 71 . 39 0 . 00 71 .39 0 . 00
1TRAVDOC FLAT RATE 1 . 00 40 . 79 0 . 00 40 .79 0 . 00
---------- - ---------- --
TOTAL PERMIT 153 . 47 0. 00 153 .47 0 .00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- ------------- -- --------
CREDIT CARD 153 . 47 VISA
---------------
TOTAL RECEIPT 153 . 47
0 opol
CITY OF CUPERTINO
CUPEkTiNO GENERAL BUILDING
PERMIT APPLICATION FORM
APN#2( _ �O (-P U ( , Q O Date: to 12( ' 0
Building Address:
7-<aO EO
Mailing Address (if different from building address):
Owner's Name: i�Ao k-di n Phone#: ^ ., ZS 02
9 '
Contractor: f i Phone:
-A I j CONST I V01cN 4�Y
Fax:
Contractor License#: c)q 2 O T 3
Cupertino Business License #: �0
Contact: A-0 r � �] Phone: �_ C�Y� 0201
D� 1 Fax:
• Residential FF Commercial
(,IILA (n e�y MVV .
Job Description:
D v p�,-�a2sz ► v o �v 2�o SVA
Building Permit Info:
Bldg ❑ Electz Plumb ❑ Mech ❑
Type of Construction (Usage Class): Occupancy Type:
1-A, 1-B ❑ II/III/V-A ❑ 11/111 B, IV-HT, V-B ®�
Valuation: Op O Square Footage:
Project Size: Express® Standard ❑ Large ❑ Major. ❑
Green Building: Please complete relevant portion of the Green Building/LEED Checklist & attach it
to the application or if applicable, include in plan set & the sheet index.
Points Achieved:
For help, contact Build it Green at www.buildit reen.or
Revised 7/01/08
aITYOFCITY OF CUPERTINO
CUPEkTINO GENERAL BUILDING
PERMIT APPLICATION FORM
Quantity/Sf Fee ID Fee Description Fee Permit Type
Group 1GENRES or
1GENCOM
1 BBOILERI For the installation or relocation of ea M
boiler/compressor to & including 3
horsepower, or ea absorption sys to &
incl 100,000 Btu/h (29.3kw)
1 BBOILER2 Installation /relocation of ea M
boiler/compressor over 3 horsepower
to &incl 15 horsepower, or ea
absorption sys over 100,000 Btu/h
1BBOILER3 Installation/relocation of ea M .
boiler/compressor over 15 horsepower
to & incl 30 horsepower, or ea
absorption sys over 500,000 Btu/h to
&incl 1,000,000 Btu/h
1 BBOILER4 Installation/relocation of ea M
boiler/compressor over 30 hosepower •
to & incl 50 horsepower, or for ea
absorption sys over 1•,000,000 Btu/h to
& incl 1,750,000 Btu/h
1 BBOILER5 Installation/relocation of ea boiler or M
refrigeration compressor over 50
horsepower, or ea absorption sys over
1,750,000 Btu/h
1 BAPPLOTH For ea appliance or piece of equip M
regulated by this Code but not classed,
in other appliance categories, or for
which no other fee is listed in this
code.
IELECINSP Other Electrical Inspections (per hour) E
1MECHINSP Other Mechanical Inspections (per M
hour)
1 PLMBINSP Other Plumbing & Gas Inspections P
(per hour)
1MEETINGIHR Application Meeting B •