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12020033
CITY OF CUPERTINO BUILDING PERMIT CONTRACTOR:MORE LAND PERMIT NO: 12020033 BUILDING ADDRESS: 10447 N BLANEY"� CONSTRUCTION OWNER'S NAME: VINOD BALAKRISHNAN 5514 AMBY DR DATE ISSUED:02/08/2012 OWNER'S PHONE: 4082032466 SAN JOSE,CA 95124 PHONE NO:(408)221-0892 11 LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ELECT f— PLUMB License Class Lic.#R u MECH r RESIDENTIAL COMMERCIAL Contractor Date I hereby affirin that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:TEMP POWER POLE,100 AMP (commencing with Section'/7000)of Division 3 of the Business&Professions Code and that my 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 3700 of the Labor Code,for the performance of the work for which this permit is issued. Sq.Ft Floor Area: Valuation:$1200 1 have and will maintain Worker's Compensation Insurance,xs provided for by Section 3700 of the Labor Code,for the performance of the work for which this pennit is issued. APN Number:31633 11 t.00 Occupancy Type: APPLICANT CERTIFICATION I certify that t 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 PERMIT EXPIRES IF WORK IS NOT STARTED to building construction,arid hereby authorize representatives of this city to enter WITHIN 180 DAYS OF PERMIT ISSUANCE OR upon the above mentioned property for inspection purposes. (We)agree to save indemnity and keep harmless the City of Cupertino against liabilities,judgments, 180 DAYS FROM LAST CALLED INSPECTION. costs,and expenses which may accrue against said City in consequence of the granting of this permit. Additionally,the applicant understands and will comply with all non-point.source regulations per the Cupertino Municipal Code,Section Issued b y: Date: 2 cj' 9.18. Signature Dat e*� RE-ROOFS: El OWNER-BUILDER DECLARATION All roofs shall be inspected prior to any roofing material being installed.If a roof is installed without first obtaining an inspection,I agree to rernove all new materials for I hereby affirm that I am exempt from the Contractor's License Law for one of inspection. the following two reasons: 1,as owner of the property,or my employees with wages as their sole compensation, Date: Signature of Applicant: 0 will do the work,and the structure is not intended or offered for sale(Se c.1'744., Business&Professions Code) 1,as owner of the property,am exclusively contracting with licensed contractors to ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER construct the project(Sec.7044,Business&Professions Code). I hereby affirm under penalty of perjury one of the following three HAZARDOUS MATERIALS DISCLOSURE declarations: I have read the hazardous materials requirements under Chapter 6.95 of the I have and will maintain a Certificate of Consent to self-insure for Worker's California Health&Safety Code,Sections 25505,25533,and 25534. 1 will maintain Compensation,as provided for by Section 3700 of the Labor Code,for the compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health& performance of the work for which this permit is issued. Safety Code,Section 25532(a)should I store or handle hazardous material. I have and will maintain Worket's Compensation Insurance,as provided for by Additionally,should I use equipment or devices which emit hazardous air Section 3700 of the Labor(-'ode,for the performance of(tie work for which this contaminants as defined by the Bay Area Air Quality Management District I will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the permit is issued. Health&Safety Code,Sections 25505,25533,and 25534. I certify that in the performance of the work for which this permit is issued,I shall not employ, any person in any manner so as,to become subject to the Worker's Owner or aut ent: making this certificate of exemption,I Date: Compensation laws of California. If,after in, IV_ become subject to the Worker's Compensation provisions of the Labor Code,I must forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of work's APPLICANT CERTIFICATION for which this permit is issued(Sec.3097,Civ C.) I certify that I have read this application and state that the above information is Lender's Name 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 Lender's Address upon the above mentioned property for inspection purposes.(We)agree to save indemnify and keep harmless the City of Cupertino against liabilities,judgments, ARCHITECT'S DECLARATION costs,and expenses which may accrue against said City in consequence of the granting of this permit.Additionally,the applicant understands arid will comply I I understand my plans shall be used as public records. with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. Licensed Professional Signature Date CITY OF CUPERTINO FEE ESTIMATOR- BUILDING DIVISION ADDRESS: 10447 N. Blaney Ave. DATE: 02/08/2012 REVIEWED BY: jsg APN: BP#: VALUATION: 1$1,200 PERMIT TYPE: Minor Building Permit -T-PLAN CHECK TYPE: Temporary Power SFQ or Qu lex IPP' ENTAMATION 1 REAP14 p ERMIT TYPE: WORK Temp power pole SCOPE APPLIANCE/EQUIP TYPE FEE ID AMPS VOLTS BP FEES Service(incl.Temp.Power) 1 ERT<200 100 <=600 $44 Elec.Permit Fee: 1 EPERMIT $44.00 NOTE: This estimate does not include fees due to other Departments(i.e.Planning,Public Works,Fire,Sanitary Sewer District,School District,etc.). These Les are based on the Erelinina in ormation available and are only an estimate. Contact the De t or addn 7 in o. .F _ MISC ITEMS ITEMS 0 : r�.,,-l; �� , Lj PME Unit Fee: $44.00 PME Permit Fee: $44.00 Lj Work Without Permit? 0 Yes 0 No $0.00 Travel Documentation Fee: 1TR.4TI'DOC $44.00 X Select an Administrative Item ffld�4``lu,-h Commission FeeIBCB15C $1.00 SUBTOTALS: $133.001 $0.00 TOTAL FEE: $133. Revised: 1/19/2012 CITY OF CUPERTINO 5 ITEMS OF 5 PERMIT RECEIPT OPERATOR: TraciC COPY # Sec: Twp: Rng: Sub: Blk: Lot : APN . . . . . . . . : 31633111 . 00 DATE ISSUED. . . . . . . : 02/08/2012 RECEIPT # . . . . . . . . . : BS000015960 REFERENCE ID # . . . : 12020033 SITE ADDRESS . . . . . : 10447 N BLANEY AVE SUBDIVISION . . . . . . . CITY . . . . . . . . . . . . . . CUPERTINO IMPACT AREA . . . . . . . OWNER . . . . . . . . . . . . : VINOD BALAKRISHNAN ADDRESS . . . . . . . . . . : 10447 N BLANEY AVE CITY/STATE/ZIP . . . : CUPERTINO, CA 95014-2333 RECEIVED FROM . . . . : VICTOR RIVERA CONTRACTOR . . . . . . . : VICTOR RIVERA LIC # 28320 COMPANY . . . . . . . . . . : MORE LAND CONSTRUCTION ADDRESS . . . . . . . . . . : 5514 AMBY DR CITY/STATE/ZIP . . . : SAN JOSE, CA 95124 TELEPHONE . . . . . . . . : (408) 221-0892 FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ----------- ------------- ---------- ---------- ---------- ---------- ----------- 1BCBSC VALUATION 1,200 .00 1 . 00 0 .00 1 . 00 0 . 00 1BSEISMICR VALUATION 1, 200 .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 133 .50 0 .00 133 . 50 0 . 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CASH 133 .50 2 X 100 BILLS --------------- TOTAL RECEIPT 133 .50 VOICE ID DESCRIPTION VOICE ID DESCRIPTION ----------------------------- -------- -------------------------------- 402 TEMPORARY POWER Building Department City Of Cupertino 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# b O OWNER'S NAME: �" '�v�© 'QCs\0. " < S�^ '�nV,�-� PHONE# 1- GENERAL CONTRACTOR: \IN Q-1BUSINESS LICENSE# ADDRESS: 1 - 5`1 �A\.j I 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 CONTIRACTOR AND ALL SUBCONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE. 4e I am not using any subcontractors: *kak C2, Signature Date Please check applicable subcontractors and complete the following information: SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets & Millwork Cement 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 Owner/Contractor Signature Date GENERAL PERMIT APPLICATION MEP COMMUNITY DEVELOPMENT DEPARTMENT-BUILDING DNISIO 10300 TORRE AVENUE-CUPERTINO, CA 95014-3255 (408)777-3228-FAX(408)777-3333- buildingecupertino.ora CUPERTINO misc ❑PLUMBING ❑MECHANICAL ELECTRICAL ❑MISCELLANEOUS PROJECT ADDRESS � � �� APN# OWNER NAME 0 � � ` � t �11�G tit. PHONE; �, � `�`i �t. E-MAIL STREET ADDRESS ` CITY, TATE,ZIP 1 k� FAX CONTACT NAME PHONE E-MAIL STREET ADDRESS ,STATE, ZIP _ FAX ❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT CONTRACTOR NAME V, LICENSE NUMBER <i LICENSE TYPE BUS.LIC# COMPANY NAME + E-MAIL �AX STREET ADDRESS CITY,STATE,ZIP PHONE2, ARCHITECTIENGINEER NAME LICENSE NUMBER BUS.LIC# COMPANY NAME' E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE USE OF SFD or DUPLEX ❑ MULTI-FAMILY PROJECT IN WMDLAND ❑ YES PROJECT IN ❑YES IS THE BLDG AN ❑YES BUILDING: - ❑COMMERCIAL URBAN INTERFACE AREA NO FLOOD ZONE RNO EICHLER HOME? ,;'NO DESCRIPTION OF WORK -- TOTAL VALUATION: �Co, RECEIVED BY: 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 have read this application and the information I have provided is correct.,have read the Description of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating.to building cons truc' Drize representatives of Cupertino to enter the above-identified property for inspection pu@oses. Signature of Applicant/Agent: Date: .L�� l a___ SUPPLEMENTAL INFORMATION REQUIRED OFFICE USE ONLY !J OVER-THE-COUNTER G ❑ EXPRESS U W ❑ STANDARD T U ❑ LARGE a ❑ MAJOR AffPMIscApp_2011.doc revised 06/21/11