12030129 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10856 BROOKWELL DR CONTRACTOR:PETER CONSTRUCTION PERMIT NO: 12030129
OWNER'S NAME: RAJESI-ISI-IAII 5925 TOMPKINS DR DATE ISSUED:03262012
OWNER'S PHONE: 4082557043 SAN JOSE,CA 95129 PHONE NO:(408)529-6412
❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT r PLUMB r
License Class Lic.p_ g�"S r r r
� MECH RESIDENTIAL COMMERCIAL
Contractor {^ Date_O 3/ ZG/ I�+
1 hereby alfir that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION: RESIDENTIAL SERVICE;UPGRADE TO 200AMPS
(commencing with Section 7000)of Division 3 of the Business&Professions
Code and that my license is in full force and effect.
1 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:$1750
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:36921026.00 Occupancy Type:
APPLICANT CERTIFICATION
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 stale laws relating PERMIT EXPIRES IF WORK IS NOT STARTED
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save WITHIN 180 DAYS OF PERMIT ISSUANCE OR
indemnify and keep harmless the City of Cupertino against liabilities,judgments, l80 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 undemlands and will comply fZ 2—C,9wii h8 all non-point source regulations per the Cupertino Municipal Code,Section Issued b Date:
Signature Date o
RE-ROOFS:
❑ N'NF,R-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 remove all new materials for
1 hereby affirm that 1 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. Signature of Applicant: Date:
will do the work,and the structure is not intended or offered for sale(Sec.7044,
Business&Professions Code)
I,as owner of the property,am exclusively commeting with licensed contmetors 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: 1 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(x)should 1 store or handle hazardous material.
1 have and will maintain Worker's Compensation Insurance,as provided for by Additionally,should I use equipment or devices which emit hazardous air
Section 3700 of the Labor Code,for the performance of the work for which this contaminants as defined by the Bay Area Air Quality Management District 1 will
permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
I certify that in the performance of the work for which this permit is issued,I shall Health&Safety Code,Sections 25505,25533,and 25534.
not employ any person in any manner so as to become subject to the Worker's Owner or authoriz gent:.
Compensation laws of Califomia. If,afer making this certificate of exemption,I Dale: /y 3/ WI/
f 2�
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,
costs,and expenses which may accrue against said City in consequence of the ARCHITECT'S DECLARATION
granting of this permit.Additionally,the applicant understands and will comply 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: 10856 brookwell dr. DATE: 03/26/2012 7REVIEWED BY: bob s.
APN: BPIF: 'VALUATION: $1,750
°PERMIT TYPE: Electrical Permit PLAN CHECK TYPE: Alteration /Addition / Repair
PRIMARY SFD or Duplex PENTAMATION 1REAP2
USE: PERMIT TYPE:
WORK residential service upgrade to 200 amps
SCOPE
APPLIANCE/EQUIP TYPE. FEE ID QTY UNITS BP FEES
Services 1ERT<200 100 Amps $44
TOTALS: F $44.00
,llech. Plan(_'heck Plumb. P/on Cheek Elec.Plan Cheek 1 0.0 1 hrs $0.00
,Nrch. Pern,d Fee: Plrrnrh. pe"mir Facc Elec. Permit Fee: IEPERMIT
orher,llceh. Inrp. Odra Plumh Insp. Li
Other Elec. Insp. 0.0 hrs $44.00
;i1rch. hap. 1, r: Phnnh. hrxp. Fee: h.'/cc.Insp. Fre:
NOTE: This estimate does not include fees due to other Departments(ie. Planning, Public Works, Fire,Sanitary Sewer District,School
District,etc.). Thesefees arebased on the prellmina information available and are only an estimate. Contact fire De t or addn 7 info.
FEE ITEMS(Fee Rcsohdion 11-053 Elf 7//111) FEE QTY/FEE MISC ITEMS
Plan Check Fite:
Suppl. PC Fee
PME Plan Check: $0.00
Pr.•rmil Fee:
Suppl. hap Fee
PME Unit Fee: $44.00
PME Permit Fee: $44.00
Construcuon Tax:
Administrative Fee: ]ADMIN $41.00
Work Without Permit? O Yes Q No $0.00
1 dremeeel Planning Fees
Travel Documentation Fee: ITRAVDOC $44.00
Strone Motion Fee: ISSEISMICR $0.50 Select an Administrative Item
Blde Stds Commission Fee: IRCRSC $1.00
SUBTOTALS: $174.50 $0.001 TOTAL FEE: $174.50
Revised: 1/19/2012
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GENERAL PERMIT APPLICATION M E P
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DNISION
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 M I
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CUPERTINO (408)TT7-3228• FAX(408)TT7-3333• building a)cuoertino.orD
/ ❑PLUNBINO MECHANICAL ELECTRICAL O MMCELLANEOUS
Xl ' PROIEC[ADDRESS I b $ 5 6 _L L ' APN p
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OWNERNAME RAIeS" SK�� PHONE q-Os-�S�'I"L(�3 E-MAIL �1�,�- -Lc�eDl, ,.�e5r+oCm
STAEETADDRESS 'OS33( aRCn?C U-%f LL r[� - CTrY,STATE,ffi GUPrci2'IrIVTJ,.cA�95a14 FAX
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CONTACT NAME F ?p4e— k�� PHONE A4O9-5�q_ '1��/ EE--MAD;
STREETADDRESS tJcI151 .—(cWPKI,�G 9.��1. C) Y,STATE.LIP C'._ "_I-r00'S£ ,TCA , 15(� FAX
❑OWNER ❑ OwNER-Bran R ❑ OWNER AGENT .6 CONTRACTOR ❑coNTRACTOR AGENT ❑ ARCIPrER ❑ENCINM ❑ DEVMOPER ❑TENAM
CONTRACTOR NAME IA/
fe-rm ; __ cn LICENSE NUMBER rrl "IA�L7��. LICENSE TYPE BUS.I.1C9
COMEANYNAME fE-ICK Gr`JSSTKL)C.-( 10r.,j E-MAIL 7J '1'TO FAX
STREET ADDRESS 5 q a� TumP�rvG� '�R. crrr,srATE ffiS'A�I ciS l aq PHONE 140
ARCHrTEGTIENGWEER NAME UCENSE NUMBER BUS.IJC R
COMPANY NAME' .E-MAIL FAX
STREET ADDRESS CITY.STATE,ZIP PHONE
USE OF ®SFD.OUPLEX ❑ MULTI-FAMILY PROIELTBIWBDLND ❑ YES PROIEL7 DI C]YES
OTHE BLDG AN ❑YES
IRRLDINO: CDMaffRCPAl. URBAN BITERFACE AREA 13NO FLOOD ZONE El NO OCHIER HOME! ❑NO
DESCRIPRON OF WORK
EL-EL-ta I GA-L Ar�LL 0 P GI R A126 TU JBZS ATAP.
X TOTALVALUATION: I9-SO - RECEIVED BY: f
l By my signs=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 1 have provided is correct J have read the Description of Work and verify it is accurate. 1 agree to comply with all applicable local
ordinances and state laws relating to building construction. 1 th tatives of Cupertino to enter the above-identified property for inspection plgoses.
Signature of Applicant/Agent _ Date: J / 'Z dr / 12 '
SUP AL INFORMATION REQT1= OFFICCEE USE ONLY
u Et OVER-THE-COUNTER
❑ EXPRESS
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m ❑ STANDARD
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❑ LARGE
❑ MAJOR
MBPMucApp_2011.doc revised 06121111