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11060208 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 22721 MEDINA LN CONTRACTOR PERMIT NO: 11060208 OWNER'S NAME: MBR LLC DATE ISSUED:06/27/2011 011"*'ER'S PHONE: 6507967982 PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ELECT PLUMB� License Class Lic.# MECH r RESIDENTIAL r COMMERCIAL F_ Contractor Date 1 hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:ADDING LIGHT FIXTURES THROUGHOUT SINGLE (commencing with Section 7000)of Division 3 of the Business&Professions FAMILY Code and that my license is in full force and effect. DWELLING 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 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 Sq.Ft Floor Area: Valuation:$300 permit is issued. APPLICANT CERTIFICATION APN Number:34230003.00 Occupancy Type: 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 PERMIT EXPIRES IF WORK IS NOT STARTED indemnify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City in consequence of the WITHIN 180 DAYS OF PERMIT ISSUANCE OR granting of this permit. Additionally,the applicant understands and will comply 180 DAYS FROM LAST CALLED INSPECTION. with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. Signature Date Issued by: Date: OWNER-BUILDER DECLARATION RE-ROOFS: I hereby affirm that I am exempt from the Contractor's License Law for one of All roofs shall be inspected prior to any roofing material being installed.If a roof is the following two reasons: installed without first obtaining an inspection,I agree to remove all new materials for I,as owner of the property,or my employees with wages as their sole compensation, inspection. will do the work,and the structure is not intended or offered for sale(Sec.7044, Business&Professions Code) Signature of Applicant: Date: I,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044,Business&Professions Code). ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER I hereby affirm under penalty of perjury one of the following three declarations: I have and will maintain a Certificate of Consent to self-insure for Worker's HAZARDOUS MATERIALS DISCLOSURE Compensation,as provided for by Section 3700 of the Labor Code,for the I have read the hazardous materials requirements under Chapter 6.95 of the performance of the work for which this permit is issued. California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain I have and will maintain Worker's Compensation Insurance,as provided for by compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health& Section 3700 of the Labor Code,for the performance of the work for which this Safety Code,Section 25532(x)should I store or handle hazardous material. Additionally,should I use equipment or devices which emit hazardous air permit is issued. contaminants as defined b the Ba Area Air y y Quality Management District I will I certify that in the performance of the work for which this permit is issued,I shall maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the not employ any person in any manner so as to become subject to the Worker's Health&Safety Codef on 5505,25533,and 25534. Compensation laws of California. If,after making this certificate of exemption,I become subject to the Worker's Compensation provisions of the Labor Code,I must Owner authgr' a /forthwith comply with such provisions or this permit shall be deemed revoked. Date: APPLICANT CERTIFICATION � TRUCTION LENDING AGENCY` I certify that I have read this application and state that the above information is I hereby affirm that there is a construction lending agency for the performance of work's correct.I agree to comply with all city and county ordinances and state laws relating for which this permit is issued(Sec.3097,Civ C.) to building construction,and hereby authorize representatives of this city to enter Lender's Name upon the above mentioned property for inspection purposes.(We)agree to save indemnify and keep harmless the City of Cupertino against liabilities,judgments, Lender's Address 's,and expenses which may accrue against said City in consequence of the ting of this permit.Additionally,the app icant understands and will comply ARCHITECT'S DECLARATION with all non-point source reLlatio�ns he u e ino Municipal Code,Section 9.18. 1 understand my plans shall be used as public records. Signature Date © Licensed Professional Building Department City Of Cupertino LM 10300 Torre Avenue Cupertino, CA 95014-3255 Telephone: 408-777-3228 C U P E RT I N O Fax: 408-777-3333 CONTRACTOR/ SUBCONTRACTOR LIST JOB ADDRESS: �-PERMIT# 51 Z� OWNER'S NAME: IC4 PHONE# d 45 -7246 GENERAL CONTRACTOR: BUSINESS LICENSE# ADDRESS: CITY/ZIPCODE: *Our municipal code requires all businesses working in the city to have a City of Cupertino business license. NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE GENERAL CONTRACTOR AND ALL SUBCONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE. I am not using any subcontractors: Signature Date Please check applicable subcontractors and complete the following information: SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets & Millwork Ce ent Finishing Electrical Excavation Fencing Flooring / Carpeting Linoleum /Wood Glass / Glazing Heating Insulation Landscaping Lathing Masonry Painting/Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile 04e Contr for Signature I -Date PROJECT DATA - RESIDENTIAL '� [Lai COMMUNITY DEVELOPMENT DEPARTMENT•BUILDIA41 0%j 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 (408)777-3228- FAX(408)777-3333 •building ancupertino.org CUPEIFi'TINOk PROJECT ADDRESS , APN# 9-' OWNER NAMEL G PHO,j�1E E-MAIL b STREET ADDRESS CITY, STATE,ZIP FAX 7 I'�O APPLICANT NAME PHONE E-MAIL STREET AD15RESS CITY,STATE, ZIP FAX ❑ OWNER OWNER-BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT w WE MUM WOM Na EXISTING USE(S): - PROPOSED USE(S): OCCUPANCY(S): TYPE OF PARCEL i CONSTRUCTION: AREA: FIRE Y N wui AREA: Y N FLOOD AREA: Y N SIESMIC AREA: Y N SPRINKLERS: Existing Proposed Floor Area: First Floor: S.f. s.f. Second Floor: s.f. s.f. Garage s.f. s.f. TOTAL: S.f. s.f. Are there at least two 10 feet by 20 feet clear spaces inside the garage? Y N `VJNf Is privacy protection planting required for the project? LOPMENT DEPAF� COMMU�111'Y f�VE BUILDING DIVISION-CUPERTINO Governing Codes: 2010 California Building Code (based on the 2009 Internatior � O) 2010 California Residential Code (based on the 2009 International R itflrnlavwful kept at the 2010 California Plumbing Code(based on tJMlJ@0€�CrV19 $1 n c to make any �,2010 California Mechanical Code(based on able 9IMPt6 g eor to deviate 2010 California Electrical Code(based on the 20001$t�io brqgdo)Buiiding Official. 2010 California Energy Code therefrom,wit out NOT 2010 California Green Building Standards stamping of this plan and spvio anon ec'sficattons SHALL ion Cupertino Municipal Code be held to permit or to be an approval of the of any provisions of any City Ordinance or State Law. � BY /d DATE 2 o Zd PERMIT NO. ProjectData-Residential.doc revised 03/09/11 GP cc! Mailing Address r P.O Box 2433 Union City,CA 94587 Phone:408-323-9032 Fax:408-323-9037 LIC#949930 TO Vipin Gupta Residence SERVICE Lighting layout 22721 Mdina Ln#A Cupertino,CA 95014 ^ ('La Phone:(650)704-3355 Load ��E-mail:vipin211@hotmaii.com '1,,, p 0 0 �D b O '� Master B O O O O O O O Bed#2 Bed#3 > �F, ® Kitchen O ® ® ® Hallway Laundry t 0 O O O O Dinning Room (D 0 , Bath#2 Sp Living Room O O Ap O O �y�l1r►�.P.�l �-1����► Waw ►� tA„ CITY OF CUPERTINO FEE ESTIMATOR- BUILDING DIVISION ADDRESS: 22721 medina dr. 7DAT7E77 06/27/2011 REVIEWED B o APN: BP#: "VALUATI N: $0 r°PERMIT TYPE: Electrical Permit PLAN CHECK TYPE: Alteration /Ad ition/ Repair PRIMARY PENTAM ION 1 REAP11 USE: SFD or Duplex I PERMIT TYP : WORK adding light fixtures throughout sfd. SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Fixtures, Lighting 1BREMFIXT 31 # $96 TOTALS: $96.001 1 Elec.Plan Check 0.0 hrs $0.00 Elec.Permit Fee: IEPERMIT L—j Other Elec.Insp. El hrs $42.00 NOTE. Theseees are based on the preliminary in ormation available and are onjV an estimate. Contact the Dept-for addh 7 info. FEE ITEMS (f E e Resolution 09-051 0) FEE QTY/FEE MISC ITEMS PME Plan Check: $0.00 PME Unit Fee: $96.00 PME Permit Fee: $42.00 Work Without Permit? 0 Yes G No $0.00 Travel Documentation Fee: ITRA VDOC $42.00 Strong Motion Fee: $0.00 0.5 hrs Admin./Clerical Fee Bldg Stds Commission Fee: $0.00 $39.00 IADMIN SUBTOTALS: $180.00 $39.00 TOTAL FEE: $219.00 Revised: 04/29/2011 OWNER-BUILDER DISCLOSURE FORM COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION 10300 TORRE AVENUE-CUPERTINO, CA 95014-3255 GUPERTtNO (408)777-3228- FAX(408)777-3333- buildingna.cupertino.org Dear Property Owner(s): An application for a building permit has been submitted in your name listing yourself as the builder of the property improvements specified at: SITE ADDRESS APN BP# OWN R A E (M` OWNER ADDRESS v n _ e" DESCRIPTION OF WORK: J6 0A-0_ •� S fi We are providing you with an Owner-Builder Acknowledgment and Information Verification Form to make you aware of your responsibilities and possible risk you may incur by having this permit issued in your name as the Owner-Builder. We will not issue a building permit until you have read, initialed your understanding of each provision, signed, and returned this form to us at our official address indicated. An agent of the owner cannot execute this notice unless you,the property owner, obtain the prior approval of the permitting authority. OWNER'S ACKNOWLEDGMENT AND VERIFICATION OF INFORMATION (DIRECTIONS:Please read and initial each statement below to signify you understand or verify this information.) NX/fNX I understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner- Builder" building permit that erroneously implies that the property owner is providing his or her own labor and material personally. I, as an Owner-Builder, may be held liable and subject to serious financial risk for any injuries sustained by an unlicensed person and his or her employees while working on my property. My homeowners insurance may not provide coverage for those injuries. I am willfully acting as an Owner-Builder and am aware of the limits of my insurance coverage for injuries to workers on my property. Z2. 1 understand building permits are not required to be signed by property owners unless they are responsible for the construction and are not hiring a licensed Contractor to assume this responsibility. 1 understand as an "Owner-Builder' I am the responsible party of record on the permit. I understand that I may pwct myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her name instead of my own. \4. I understand Contractors are required by law to be licensed and bonded in California and to list their license numbers on permits and contracts. 5. I understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the total value of my construction is at least five hundred dollars ($500), including labor and materials, I may be considered an "employer" under state and federal law. 1 understand if I am considered an "employer" under state and federal law, I must register with the state and federal government, withhold payroll taxes, provide workers' compensation disability insurance, and contribute to unemployment compensation for each "employee." I also understand my failure to abide by these laws may subject me to serious financial risk. <V/7. 1 understand under California Contractors'State License Law, an Owner-Builder who builds single-family residential structures cannot legally build them with the intent to offer them for sale, unless all work is performed by licensed subcontractors and the number of structures does not exceed four within any calendar year, or all of the work is performed under contract with a licensed general building Contractor. s$. I understand as an Owner-Builder if I sell the property for which this permit is issued, I may be held liable for any financial or personal injuries sustained by any subsequent owner(s)that result from any latent construction defects in the workmanship or materials. OwnerBuilderFonn 2010.doc revised 04/14/10 9. 1 understand I may obtain more information regarding my obligations as an "employer"from the Internal Revenue Service, the United States Small Business Administration,the California Department of Benefit Payments, and the California Division of Industrial Accidents. I also understand I may contact the California Contractors' State License Board (CSLB)at 1-800-321-CSLB (2752)or www.csib.ca.gov for more information about licensed contractors. —\P0"I am aware of and consent to an Owner-Builder building permit applied for in my name, and understand that I am the party legally and financially responsible for proposed construction activity at the site address listed above. 1 1 agree that, as the party legally and financially responsible for this proposed construction activity, I will abide .40 by applicable laws and requirements that govern Owner-Builders as well as employers. I agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the information I have provided on this form. Licensed contractors are regulated by laws designed to protect the public. If you contract with someone who does not have a license, the Contractors' State License Board may be unable to assist you with any financial loss you may sustain as a result of a complaint. Your only remedy against unlicensed Contractors may be in civil court. It is also important for you to understand that if an unlicensed Contractor or employee of that individual or firm is injured while working on your property, you may be held liable for damages. If you obtain a permit as Owner-Builder and wish to hire Contractors, you will be responsible for verifying whether or not those Contractors are properly licensed and the status of their workers' compensation insurance coverage. CONSTRUCTION LENDING AGENCY (DIRECTIONS:Please complete the following construction lending agency information.) I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Sec 3097 Civ.) Lender Name: Lender Address: Before a building permit can be issued,this form must be completed and signed by the property owner and returned to the agency responsible for issuing the permit. Note:A copy of the property owner's driver's license, form notarization, or other verificationceptable to city may be required to be presented when the permit is issued to verify the property owner's si nature. Property Owner's Signature: Date: - - --- --------- i -w- - - -------- -- -------- ----------------------------------------------------------------------------------------- (NOTE: The following Authorization Form is required to be completed by the property owner only when designating an agent of the property owner to apply for a construction permit for the Owner-Builder). AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF Excluding the Notice to Property Owner, the execution of which I understand is my personal responsibility, I hereby authorize the following person(s)to act as my agent(s)to apply for, sign, and file the documents necessary to obtain an Owner-Builder Permit for my project. Scope of Construction Project(or Description of Work): Project Location or Address: d Name of Authorized Agent: Tel No Address of Authorized Agent: I declare under penalty of perjury that I am the property owner for the address listed above and 1 personally filled out the above information and certify its accuracy. Note:A copy of the property owner's driver's license, form notarization, or other verification acceptable to the city may be required to be presented when the permit is issued to verify the property owner's signature. Property Owner's Signature: Date: OwnerBuilderForns 2010.doc revised 04114/10 CITY OF CUPERTINO 6 ITEMS OF 6 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN . . . . . . . . : 34230003 . 00 DATE ISSUED. . . . . . . : 06/27/2011 RECEIPT #. . . . . . . . . BS000013893 REFERENCE ID # . . . : 11060208 SITE ADDRESS 22721 MEDINA LN SUBDIVISION . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . OWNER MBR LLC ADDRESS 22721 MEDINA LN CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM . . . . : VIPIN GUPTA 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 ------------- ---------- ---------- ---- -ADMIN HOURS 0 .50 39.00 0. 00 39. 00 0. 00 1BCBSC VALUATION 300 .00 1. 00 0. 00 1 .00 0. 00 1BREMFIXT NO. FIXTURES 31. 00 96 . 00 0 . 00 96 . 00 0. 00 1BSEISMICR VALUATION 300 .00 0. 50 0. 00 0 .50 0 .00 1EPERMITFE FLAT RATE 1. 00 42 . 00 0 . 00 42 .00 0. 00 1TRAVDOC FLAT RATE 1.00 42.00 0. 00 42 . 00 0. 00 ---------- ---------- ---------- ---------- TOTAL PERMIT 220 .50 0 . 00 220 .50 0.00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CREDIT CARD 220. 50 AMEX --------------- TOTAL RECEIPT 220. 50 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ------------ 304 ROUGH ELECTRICAL 501 FINAL ELECTRICAL ENERGY 505 FINAL ELECTRICAL 512 FINAL HANDI-CAP ( 0(-,o ozC)'? GENERAL PERMIT APPLICATION MEP COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255La MISC (408)777-3228• FAX(408)777-3333• building(aDcupertino.org CUPERTINO PLUMBING MECHANICAL ELECTRICAL ^^^^���� ❑MISCELL/ANEOUS PROJECT ADDRESS 22- 2 , L v //J APN# A ✓, L .. OWNER NAME h� t G PHONE E-MAIL STREET ADDRESS 1.� Z '✓ ���f �� CITY, STATE,ZIP r p�(�^„� /L FAX CONTACT NAME _-w' PHONE (, C.1 jYli E"("�IL� STREET ADDRESS CITY,STATE, ZIP FAX ❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME r 1' 1 f 14- 1 G�e j 1 LICENSE NUMBER �� n D LICENSE TYPE BUS.LIC# r c� vl COMPANY NAM E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP f_" (A PHONE �)0 7 2_3 ,G� 32— Goy 2 4 3 3 (� 1 'T J ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC# COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE USE OF UWDor DUPLEX [:I MULTI-FAMILY PROJECT IN W ILDLAND ❑ YES PROJECT IN ❑YES IS THE BLDG AN ❑ YES BUILDING: ❑COMMERCIAL URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑NO �EICHLER HOME? ❑NO DESCRIPTION OF WORK 1 f / X�,,,' ^ b p " ko4j I , TOTAL VALUATION: D D. 13� RECEIVED B1': By my signature below,I certiff to each of the following: I am the property owner or authorized agent to act on the property owner's behalf. I have read this application and the information I have provided is correct ltkkveLpd the Description of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating to buil ng cons do authorize representatives of Cupertino to enter the above-identified property for inspection pu{poses. Signature of Applicant/Agent: r Date: SUP ENT L RMATION REQUIRED OFFICE U E ONLY U'-OVER-THE-COUNTER ❑ EXPRESS U ❑ STANDARD U ❑ LARGE L ❑ MAJOR MEPMiscApp_201].doe revised 06/21/11 0 -i p m C :03 m Cl) 0 -a O 3 CD Z ao .••irncn � wNr- i-- � a Q• n 6 ' t� DCvv � ��?� o 3 N o N C7 O-y N ? 30• N c Zoe _ � 0 � co co � � to 3 ;�co .a m v n `;i0o � � o c" CD 00 �► � CD a .► 3 0 0 co m =' C C N a0 CL N w o t •2` = �f ii wl� C L _ N n C7,`z C -4 < N O C1 n �• N W O N 75 N fd c O [ � (A O t6 O > N -30 < 'O O O =h U Q�j -�� CD 0 m 3 0 '' c� � — rt N m 0 0 rt p N co N Oi• < > `G CD Q 1 0 O O O O CD 3 v cD + + 3 fl1 0 3 m N m m CA ro m cn N CA -4 `4 �N °° 00N -� w tG 0 O CA < y w o b o D ooinocncoo lT1y o o o = 0000u, 00 �s � oo � 3 0 5D3 OOoo000 a -a �G 000000o oo . � o o� n 0 0 0 0 0 0 0 0 0 0 o o 0 CD m CD 0 r+ n fi -n v C o< cfl c, 3 0 0 o p o O o N w v+ 0000000CTCJ� jn ? p0 c 0 0 0 000 0 00 0 O O O O (D p � N f o < O O N N Ca W CT W CP O p ooinoc�+ coo � o y D N N 0 Cl 0 0 c" 0 0 00 Cp 3 b v 0000000 W 0 o Q O �� G p00000aCo O N (D O r O