08110055 BUILDING DIVISION PERMIT
C�NTRA.CTNOI2INI'URMATIQ„NP
BUILDING ADDRESS: PERMIT NO.
5941 BOLLINGER RD BOLLTBD – TO RR F)FTERMTNED ngiinn—
OWNER'S NAME: PERMTr ISSUE DATE
9
A CONTROL NO.
ARCHI'IECfrENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
raj LICENSED CONIRACIDRS DECLARATION Job Description
UW 1 bamby aRrm that I aA licmed under provisions of Ckapur 9(Commercing
viN Bastion 7000)ef Division lof Jur Busircasand Profrations ode.ard mylkeruca
+ „ imm�rmceaM (2 CABINET REPLCMNT PULL GASLINE FM GARAGE TO STOVE
a Ll Uce�Clan Is.g
•_f,o Dam Comtranmr INKTCHEN & UPGRAD COUNTR TOP OUTLET
acts"Ib can DECURA ON
Dwu UMmanJmypuuWlbeurAuPublic oN NOTE:CABINETS PLUS BD FOR BUS LIC $110 . 00
I
LICCRmd Professions] -
=
MOWNER-BUILDER DECLARATION
m 1 hereby arrthat 1 am exempt from the Contractes License law for the
COO following mason.(Section NO 1.5.Business and Profession;Codc:Any city Of County
which requires a permit m emodruct alcor,improve,demolish.of repair any swede
_ZT prior in its imus .alw requires the applicant for such Permit m file a signed summCot
Erse thuheI,licensed pursuant mthe provisionsofdcC..=W,sUccnmLaw(Chapmr9 Sq.Ft.Floor Area Valuation
x (commencing with Section 7000)of Division 3 of tW Business and Professions Cods)or
y
than he u exempt thctefmm and the basis for the alkgcd exemption.Any violation of $8000
Section 7031.5 by any applicant for a perch subjects the applicant to a civil Penalty of APN Number Occupancy Type
no mom than BK hundred dollars(IISM. 37535022 . 00
❑1,u owner of the propvry,army employees with wgu u Ness anic compensation,
will do the work.and theswctum a intim ended buffered for.aak(Sec.7014,Business
and Professional
K Code:TCoaundtb's License Law does not apply an an owmr of Required Inspections
property who builds w im proves themon.and who does such work himself or through his
Own employers,provided that such improvements arc not intended rrrfremd for sale,If,
however.the Wilding or Improvement Is mid within one year of completion,ate owner-
builder will have the Wooden of proving that he did Out Wild or improve for purpose of
sal'.).
D 1.as ower of the property.am exclusively contracting with licensed centractas to
Constroct the project(Sec 701 Business and Profusion;Code:)Tied Contractor's U.
cmc Law does but apply to an owner of property who Wilds or impruwa thereon,and,
who contra.al for such projects with a contrmmr(s)[lensed pursuant to the Contractor's
Lieena Law.
D l can nacmpt under See .B h P C for this moon
Owner Data
WORKER'S COMPENSATION DECLARATION
1 thereby alEm under pcsuesjmft of py orc of following dccionsu ce:
am -
I have awill maintain a Certificate of Consent to self-insum for Workers compo t.
'on.' provided fo by Section 3100 of the labor Code.for the perfamhan¢of the
work for which this Permit is issued.
D 1 have and will maintain Worker's Compehuatlon human¢,as required by Section
3700.f the Labor Conc.for the perrommusexofthe work for which this permit is itaned.
My We ccder maton bswruhce friss and Poliry number am:
Cartier. PoI'hry No.:
CERTIFICATE OF •rEMF TIDN FROM WORKERS
COMPENSATION INSURANCE
Olds section recd Out uncompleted If the permit a two=hundrrd moan($I00)
Or kens)
I rutfy Nan in the Performance of the work for which this permit is IsruN,I"I not
employ my person in my manmrw as m became subject to the Workess'Cmmpensation
Laws of California.Due
Applicant
NOTICE TO APPLICANT:If.after making Nu Cerifhcme or Eaempfim.you should
become subject as the Worker's Compensation pmvisim or the Labor Code.you most
O forthwith comply with such Provisions or Nu Permit shall he deemed revoked.
CONSTRUCTION LENDING AGENCY
[-� IWreby alRm Into Nem iso mustrucimn krulingagercy for NC perfomanceuf
the work for which this permit is iuved(Sec.3097,Civ,C.)
LeMci sNam. ,
D z under.Address
V O 1 dolly Nat I have mad this application and aunt Nn the above informauun is
^'. coma I.I to.omply with all city and county oNinantes arW sunt laws mating to
.C) building construction,and hereby wNorim representatives or this city to enter upon the
L2t above-mentioned properly for inspection purposes.
(WC)acme to saw,indemnify and keep harmless the City of Cupertino against
hF-h rjj liabilities.judgmems.cosu and sap..which may in any way acerae against said City
V z in consequence of the gmnung of this Permit.
r APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date//—/ 7-0
SOURCE R TIONS.
Re-roofs
Sigm, of Ap iunK: hof Dam
H US MATERIALS DISCLOSURE Type of Roof
Will pplinn or future building uccy WL nom or handle hadardoes maurial
as defined by Cupe 'no Municipal C .Chapter 9AZ and the Health and Safety
Code.Sean 532()7 All roofs shall be inspected prior to any roofing material being installed.
Dyes o
Will be applicant or future Wilding occupant um cquipm t or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it hamom. if.nnumihunts�bythc Bay Aum Air Quality Management all new materials for inspection.
u n?
Dy.
1 her mad the hsemlousmveraa mquimmcros under Chapmr6.95afNe Giifor
out HcalthhSarctyCab%Sections 25505.25533 and25536.I undersand dmifft building
don not currently Mac a levan.Nat it u my mao
pmthility u hair Ne occupant or Nr.
rmptim ; m
m`nw band` Signature of Applicant Date
owmramdume agent Dat All roof coverings to be Class'W'or better
CITY OF CUPERTINO
• 8 ITEMS OF 8 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec : Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 37535022 . 00
DATEISSUED. . . . . . . : 11/17/2008
RECEIPT #. . . . . . . . . : BS000006624
REFERENCE ID # . . . : 08110055
SITE ADDRESS . . . . . : 5941 BOLLINGER RD
SUBDIVISION . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : PERVEZ MOHTA
ADDRESS . . . . . . . . . . : 5941 BOLLINGER RD
CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-3536
RECEIVED FROM . . . . : CABINETS PLUS
CONTRACTOR . . . . . . . : TBD - TO BE DETERMINED LIC # 00096
COMPANY . . . . . . . . . . : TBD - TO BE DETERMINED
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . .
TELEPHONE . . . . . . . . :
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
1BREMFIXT NO. FIXTURES 1 . 00 61 . 19 0 . 00 61 . 19 0 . 00
1BREMRECEP NO. OUTLETS 1 . 00 40 . 79 0 . 00 40 .79 0 . 00
}BSEISMICR VALUATION 8, 000 . 00 0 . 80 0 . 00 0 . 80 0 . 00
1BUSLIC FLAT RATE 1 . 00 110 . 00 0 . 00 110 . 00 0 . 00
IEPERMITFE FLAT RATE 1 . 00 40 . 79 0 . 00 40 . 79 0 . 00
1PPERMITFE FLAT RATE 1 . 00 40 . 79 0 . 00 40 . 79 0 . 00
1PREPPIPE FLAT RATE 1 . 00 40 .79 0 . 00 40 . 79 0 . 00
1TRAVDOC FLAT RATE 1 . 00 40 .79 0 . 00 40 . 79 0 . 00
TOTAL PERMIT 375 . 94 0 . 00 375 . 94 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CHECK 375 . 94 #1348
---------------
TOTAL RECEIPT 375 . 94
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Community Development
10300 Torre Avenue
!M1
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
IDUPEkTINO
'
Building De artment
JOBADDRESai ni PERMIT #
�YlJsollTA Def // 00_,5'
OWNER'S NAME: h PHONE #
GENERAL!CONTRACTOR: b i N FAX #
I am not us''i g any subcontractors:
Signature Date
Please check applicable subcontractors and m Tete the following information:
60 SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets &Millwork
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
Tile
ne Contractor Signature Date
CITY OF CUPERTINO
d CUPERTINO Y GENERAL BUILDING
PERMIT APPLICATION FORM
APN# Date:
75 oar _ � � 1 I OT
Building Address:
Mailing Address (if differpt from building address):
Owner's Name: Phone: 1 t,� _
Contractor: ';� Phone: i t A)-S�9
^n I of
SII* lVto " ClM � Fax: i
Contractor License : G
Cupertino Business License#:
Contact: I Phone: �0(16X�- gsbo
6eor �j �i� Fax:
• Residential I Commercial
Job Description: 4
/
5 rnP �J Oa-c M�n f c Q 61e j x0AA
aM� a co
Building Permit Info:
Bldg ❑ Elect V,- Plumb Mech eo
Type of Construction (Usage Class): Occupancy Type:
1-A, 1-B ❑ II/III/V-A ❑ II/III B, IV-HT, V-B Q
Valuation: j �ds Square Footage:
Project Size. Ex ress V
1� 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.buflditgreen.org
T,n1.v,�an C2 Revised 10/20/08
4
CITY OF CUPERTINO
CUPEkTiNO GENERAL BUILDING
PERMIT APPLICATION FORM
Quantity/Sf Fee ID Fee Description Fee Permit Type
Group 1GENRES or
1GENCOM
1BBOILERI 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
1BBOILER5 Install ation/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.
I ELECINSP Other Electrical Inspections (per hour) E
1MECHINSP Other Mechanical Inspections (per M
hour)
IPLMBINSP Other Plumbing& Gas Inspections P
(per hour
1MEETINGIHR Application Meeting B •