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12010090CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10256 GLENCOE DR CONTRACTOR PERMIT NO: 12010090 OWNER'S NAME: VENKATARAMAN SHIVAKUMAR AND ADIMO Vi L+�� `� DATE ISSUED: 01/12/2012 OWNER'S PHONE: 6>03907925 PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATIONF- BUILDING PERMIT INFO: BLDG ELECT' PLUMB License Class {% Li,. #o,5 o S r.-.- - - - MECH RESIDENTIAL' COMMERCIAL Contractor 14c ft �'% aMg /[ Date I hereby affirm that I am licensed under the provisions of hapter 9 JOB DESCRIPTION: TEMP POWER AT EXISTING SERVICE PANEL (commencing with Section 7000) of Division 3 of the Business & Professions Code and that in 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 3',•00 of the Labor Code, for the performance of the work for which this permit is issued. Sq. Ft Floor Area: Valuation: $500 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 permit is issued. APN Number: 32630029.00 Occupancy Type: APPLICANT CERTIFICATION I certify (flat I have react 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 PERMIT EXPIRES IF WORK IS NOT STARTED upon the above mentioned property for inspection purposes. (We) agree to save indemnity and keep harmless the City of Cupertino against liabilities, judgments, WITHIN 180 DAYS OF PERMIT ISSUANCE OR costs, and expenses which may accrue against said City in consequence of the 180 DAYS FROM LAST CALLED INSPECTION. granting of this permit. Additionally, the applicant understands and will comply with all non -point source regulations per the Cupertino Municipal Code, Section 9.13. Issued by:-, .- Date: ,— Signature ❑ OWNER -BUILDER DECLARATION RE -ROOFS: All roofs shall be inspected prior to any roofing material being installed. If a roof is I hereby affirm that I am exempt from the Contractor's License Law for one of installed without first obtaining an inspection, I agree to remove all new materials for the following two reasons: inspection. 1, as owner of tire property, or my employees with wages as their sole compensation, wit( do the work, and the structure is not intended or offered for sale (Sec.7044, Signature of Applicant: Date: Business & Professions Code) I, as owner of tine 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: HAZARDOUS MATERIALS DISCLOSURE I have and will maintain a Certificate of Consent to self -insure for Worker's I have read the hazardous materials requirements under Chapter 6.95 of the Compensation, as provided for by Section 3700 of the Labor Code, for the California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain performance of the work for which this permit is issued. compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & I have and will maintain Worker's Compensation Insurance, as provided for by Safety Code, Section 25532(a) should I store or handle hazardous material. Section 3700 of the Labor Code, for the performance of the work for which this Additionally, should I use equipment or devices which emit hazardous air Permit is issued. contaminants as defined by the Bay Area Air 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 Health & Safety Code, Sections 25505, 25533, and 25534. not employ any person in airy manner so as to become subject to the Worker's Compensation taws of California. If, after making this certificate of exemption, 1 O er or autt r' d gent: become subject to the Worker's t_'ompensation provisions of the Labor Code, I must l - � e �- Date: forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY APPLICANT CERTIFICATION I hereby affirm that there is a construction lending agency for the performance of work's I certify that I have read this application and state that the above information is for which this permit is issued (Sec. 3097, Civ C.) -oriect. I agree to comply with all city aW county ordinances and state laws relating Lender's Name io building construction, and hereby authorize representatives of this city to enter Liporr the above mentioned property for inspection purposes. (We) agree to save Lender's Address indemnify and keep harmless the City of Cupertino against liabilities, judgments, „osts, and expenses which may accrue against said City in consequence of the ?ranting of this permit. Additionally, the applicant understands and will comply ARCHITECT'S DECLARATION with all non -point source regulations per the Cupertino Municipal Code, Section I understand my plans shall be used as public records. ).18. Licensed Professional signature Date 6 ITEMS OF 6 CITY OF CUPERTINO PERMIT RECEIPT Sec: Twp: Rng: Sub: Blk: Lot: APN ........: 32630029.00 DATE ISSUED.......: 01/12/2012 RECEIPT #.........: BS000015740 REFERENCE ID # ...: 12010090 SITE ADDRESS .....: 10256 GLENCOE DR SUBDIVISION ....... CITY CUPERTINO IMPACT AREA ....... OPERATOR: patg COPY # : 1 OWNER ............: VENKATARAh'IAN SHIVAKU1AR AND AD ADDRESS ..........: 10256 GLENCOE DR CITY/STATE/ZIP ...: CUPERTINO, CA 95014 RECEIVED FROM ....: HEALY ELECTRIC 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 ---------- 1.00 ---------- 41.00 ---------- 0.00 ---------- 41.00 0.00 1BCBSC VALUATION 500.00 1.00 0.00 1.00 0.00 1BSEISMICR VALUATION 500.00 0.50 0.00 0.50 0.00 1EPERMITFE FLAT RATE 1.00 44.00 0.00 44.00 0.00 1ERT<200 UNITS 1.00 44.00 0.00 44.00 0.00 1TRAVDOC FLAT RATE 1.00 44.00 0.00 44.00 0.00 ---------- TOTAL PERMIT ---------- 174.50 ---------- 0.00 ---------- 174.50 0.00 METHOD OF PAYMENT ----------------- CREDIT CARD TOTAL RECEIPT AMOUNT --------------- 174.50 --------------- 174.50 REFERENCE NUMBER -------------------- VISA VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 402 TEMPORARY POWER CITY OF CUPERTINO FEE ESTIMATOR - BUILDING DIVISION ADDRESS: FEE ID DATE: 01/12/2012 REVIEWED BY: im APN: ! BP#: I VALUATION: 1$500 PERMIT TYPE: Electrical Permit PLAN CHECK TYPE: Alteration / Addition / Repair PRIMARY SFD or Dulex Amps $44 PENTAMATION 1REAP14, I USE: PERMIT TYPE: WORK temp power at existing service panel. PME Unit Fee: $44.00 PME Permit Fee: SCOPE APPLIANCE / EQUIP TYPE FEE ID Lj I I QTY UNITS BP FEES Temporary Power 1 ERT<200 100 Amps $44 Lj PME Unit Fee: $44.00 PME Permit Fee: $44.00 Ll Administrative Fee: JADMIN $41.00 Work Without Pert -nit? 0 Yes 0 No $0.00 TOTALS: Travel Documentation Fee: I TR4 VDOC $44.001 lvlohor� Fe,�� IBSEISAIfICR A,'OTE: This estimate does not include fees due to other Departments (Le. Planning, Public Works, Fire, Sanitary Sewer District, School Dictrirt- eir- I- Tho.vo fees an, hased an the nre-lininary information available and are only an estimate. Contact the Dept for addn 7 info. FEE ITEMS Lj Lj I I Elec. Plan Check 0.0 1 hrs $0.00 Elec. Permit Fee: ]EPERMIT Other Elec. Insp. LE hrs] $44-00 A,'OTE: This estimate does not include fees due to other Departments (Le. Planning, Public Works, Fire, Sanitary Sewer District, School Dictrirt- eir- I- Tho.vo fees an, hased an the nre-lininary information available and are only an estimate. Contact the Dept for addn 7 info. FEE ITEMS FEE QTY/FEE MISC ITEMS PME Plan Check: $0.00 Lj PME Unit Fee: $44.00 PME Permit Fee: $44.00 Ll Administrative Fee: JADMIN $41.00 Work Without Pert -nit? 0 Yes 0 No $0.00 Travel Documentation Fee: I TR4 VDOC $44.00 lvlohor� Fe,�� IBSEISAIfICR $0.50 Select an Administrative Item FeeIBCBSC $1.00 SUBTOTALS: $174.50 1 $0.001 TOTAL FEE: $174.501 Revised: 1 /01 /2012 Building Department City Of Cupertino ELI] 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: /0 7 S tvc o e Or, PERMIT OWNER'S NAME:�It/Vj ()jZ VelvK Afjl - W AA) PHONE # % SO 3 ? V GENERAL CONTRACTOR: 14 Ell j, I w L 1i l?- ►C BUSINESS LICENSE # ADDRESS: 1,?b 5 � - 1-:7 ST CITY/ZIPCODE: & -2 C�} �yU415/ *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. , / ZZ I am not using any subcontractors: // 7P—LSigt,at&e04te Please check applicable subcontractors and complete the fo owing information: / C6nwractoN2nature ///Z// ate SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets & Millwork Cement Finishing Electrical 71 I C 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 / C6nwractoN2nature ///Z// ate GENERAL PERMIT APPLICATION `` MEP COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 MISC CUPERTINO�1,�j M PT T TMRTNC: n MECHANICAL 1WELEC MCAL n N'asc I.ANEovs (408) 777-3228 •FAX (408) 777-3333 • building(a�cupertino.or PROJECT ADDRESS /) / _ L ��/Lc7P f�. AFN # ✓ - C� OWNERNAME {{ I ' 1 1'\'014 V F /�' H ,1 S I 1 � V 1 � � V 1' / �/ G� �'[ /'i � �% I�/1 PHOI� rC% 7 �lO 712 F.mAm sTRE>;rAD 0 2-S 6 LeovC O P /�ie cmr, srarE, ZIP ✓ 1'7`� a/ FAx CONTACT NAME PHONE 77kIL STREET ADDRESS CITY, STATE, ZIP FAX ❑ OwNER ❑ OWNER -BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTvR NAME ,/jy] j L. / fiG LICENSE NUMBER �j� < / % LICENSE TYPE f BUS. LIC # COMPANY NAME • l /J. L IG �/' / /t Y -MAIL /^ �Gi I Com! P C f %'/ C%A M�i7 4/ FAX STREET ADDRESS i�� sU�W>` sT CITY STATE, ZIP .4c;�,c;3 PHONE 3d9 1? ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS. LIC # COMPANY NAME ' E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE USE OF W SFD or DUPLEX ❑ MULTI -FAMILY BUIIAING: ❑ COMMERCIAL PROJECT IN WILDLAND ❑YES URBAN INTERFACE AREA ❑ NO PROJECT IN ❑ YES FLOOD ZONE ❑ NO IS THE BLDG AN ❑ YES EICHLER HOME? ❑ NO DESCRIPTION OF WORK G�i V % ^� f✓/'l k� /� j��o �iJj TWe Ex- S f'1 /v,G ' l// c i /V� Tfv;ezC fig w /C'_,2 LI r� x I TOTAL VALUATION: S C RECEIVEDBY: By my signature below, I certify to each of the following: I am the property owner or authorized agent to act on the property owner's behalf. I bave read this application and the information I have provided is correct. j have read the Description of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating g cons c 'on. I authorize representatives of Cupertino to enter the above-iden ' ed property for inspection pu{-poses. Signature of Applicant/Agent: Date: Z Z S LEMENT INF TION REQUIRED OFFICE USE ONLY e. Y U W S U G � Lr OVER-THE-COUNTER ❑ EXPRESS ❑ STANDARD ❑ LARGE ❑ MAJOR MEPMJscApp_2011.doc revised 06/21/11