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07030225 .-77777-77777-7777777 CITY OF CI1PERTINO STT Q R j ` } 1 $4TIQN BUILDING DIVISION ]PERMIT 1 PERMIT NO. BUILDING ADDRESS: TBD — TO BE DETERMINED 07030225 22975 BALBOA RD _ PERMIT ISSUE DATE OWNER'S NAME: 03/2 3/2 0 0 7 �IMAR GUPTA SANITARY NO. CONTROL NO, NE: BUILDING PERMIT INFO ARCHITECT/ENGINEER: BLDG ELECT PLUMB MECH Z LICENSED CONTRACTOR'S DECLARATION Job Description O I hereby affirm that I am licensed under provisions of Chapter 9(commencing U with Section 700(1)of Division 3 of the Business nd Professions Code,and my license is INSTALL 100 AMP PANEL—ADVANCED CIRCUIT ELEC TR H in full farce and effect #28808 HAS CURRENT BL. K License Class — Contractor _tp Date ARCHITECTS DECLARATION E I understand my plans shall be used as public records �a yU L HLicensed Pmfcssional a OWNER-BUILDER DECLARATION ai hereby affirm that 1 am exempt from the Contractor's License Law for the ❑O following reason.(Section 703 1.5,Business and Professions Code:Any city or county Pi which requires a permit to construct,alter,improve,demolish,or repair any structure Valuation r, prior to its issuance,also requires the applicant for such permit to file a signed statement Sq Ft.Floor Area z a that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 $500 F (commencing with Section 7000)of Division 3 of the Business and Professions Code)or that he is exempt therefrom and the basis for the alleged exemption.Any violation of Occupancy Type Section 7031.5 by airy applicant for a permit subjects the applicant to a civil penalty of 3423100- . `` Number not more than five hundred dollars(5500). ❑1,as owner of the property,or my employees with wages as their sole compensation, Required Inspections will do the work,and the structure is not intended or offered for sale(Sec.7044,Business and professions Code:The Contractor's License Law does not apply o an owner of property who builds r improves thereon,and who does such work himself or through his own employees,provided that such improvements are not intended or offered for sale.If, however,the building or improvement is sold within one year of completion,the owner- builder will have the burden of proving that he did not build or improve for purpose of sale.). ❑I,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044.Business and Professions Code:)The Contractor's U- oaf property who builds or improves thereon,and. who contracLaw does or such pronot apply j ects cis with aan rcontractor(s)litensed pursuant to the Contractor's License Law. B&P C for th- reason ❑1 am exemp Oder Sec _ 3 2a Owner Date ORKER'S C MPE 7SATION DECLARATION I hereby, rrm under penalty of perjury ane of the following declarations: ❑I have and will maintain a Certificate of Consent to self-insure for Workei s Compen- QA sation,as provided for by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. ,,,___,N1TARY ❑I have and will maintain Worker's Compensation Insurance,as required by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. My Worker's Compensation insurance carrier and Policy number are: Cartier. Policy No.: CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed if the permit is foronc hundred dollars($100) or less.) I certify that in the performance of the work for which this permit is issued.I shall not employ any person in any mann u o bcpc c subject to the Workers'Compcttsation Laws of California.Date `y Applicant_ . NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should become subject to the Worker's Compensation provisions of the Labor Code,you must Z forthwith comply with such provisions or this permit shall be deemed revoked. Z, CONSTRUCTION LENDING AGENCY E^t rte-. 1 hereby affirm that there is a construction lending agency for the performance of fY� the work for which this permit is issued(Sec.3097,Civ.C.) Lender's Name 0 z Lender's Address 1 certify that I have read this application and state that the above information is O correct.1 agree to comply with all city and county ordinances and state laws relating to rJ U building construction,and hereby authorize representatives of this city to enter upon the about-mentioned property for inspection purposes. a (We)agree to save,indemnify and keep harmless the City of Cupertino against Hliabilities,judgments,costs and expenses which may in any way accrue against said City U Z in consequence of the granting of this permit. (' Date APPLICANT UNDERST DS AND WI COMPLY WiTH ALL NON-POINT Issued by: SOURCE REGULATION 3 TLS Re-roofs Signature of Applicant/Contra for Dao Type of Roof HAZAR OUS MATERIALS DISCLOSURE YP Will the applicant or future building occupant store or handle hazardous material as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety Code,Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed. ❑Yes Na If a roof is insl ailed without first obtaining an inspection, agree to remove Will the applicant or f turc building occupant use equipment or devices which emit hazardous air contaminants as defined by the Bay Arca Air Quality Management all new materials for inspection. District? ❑YesNo 1 have read the hazardo s materials requirements under Chapter 6.95 of the Califor- nia Health&Safety Code,Scct;lons 25505,25533 and 25534.1 understand that if the building docs not curre ly have a tenant,that it is my responsibility to notify the occupant of the Date requirements c must be me rior o issuance of a Certificate oIS, pan Signature of Applicant �� All roof coverings to be Class"B" or better Owner or authorized agent Date CITY OF CUPE RTINO 3 ITEMS OF 3 PERMIT RECEIPT OPERATOR: suew COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN 34231001. 01 DATE ISSUED. . . . . . . : 03/23/2007 RECEIPT #. . . . . . . . . : BS000000768 REFERENCE ID # . . . : 07030225 SITE ADDRESS 22975 BALBOA RD SUBDIVISION . . . . . . CITY . . . . . . . . . . . . . : CUPERTINO IMPACT AREA . . . . . . . OWNER . . . . . . . . . . . . : AMAR GL;PTA ADDRESS . . . . . . . . . . . CITY/STATE/ZIP . . . : , RECEIVED FROM . . . . : RECEIPT INTERFACE CONTRACTOR . . . . . . . : TBD - 70 BE DETERMINED LIC # 00096 COMPANY . . . . . . . . . . : TBD - ZO BE DETERMINED ADDRESS . . . . . . . . . . . CITY/STATE/ZIP . . . : TELEPHONE . . . . . . . . : FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ------ ---- ---------- -- BELEC200 METERS 1.00 X9.43 0 .00 29.43 0.00 BSEISMICRE VALUATION 500.00 0.50 0 .00 0 .50 . 0.00 EPERMITFEE FLAT RATE 1.00 ;-8.37 0.00 38 .37 0. 00 ------ ---- ---------- ---------- ---------- TOTAL PERMIT ('18.30 0 .00 68 .30 0. 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- --------------------- CHECK 68.30 19'13 --------------- TOTAL RECEIPT 68.30 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- -------------- 103 UFER 304 ROUGH ELECTRICAL 505 FINAL ELECTRICAL CITY OF CU:?ERTINO 3 ITEMS OF 3 PERMIT RECEIPT OPERATOR: suew COPY Sec: Twp: Rng: Sub: Blk: I,ot: APN 34231001. 01 DATE ISSUED. . . . . . . : 03/232007 RECEIPT 4. . . . . . . . . : BSOO0000768 REFERENCE ID # . . . : 0703025 SITE ADDRESS 22975 BALBOA RD SUBDIVISION . . . . . . CITY CUPER7INO IMPACT AREA . . . . . . OWNER AMAR GUPTA ADDRESS . . . . . . . . . . : CITY/STATE/ZIP , RECEIVED FROM . . . . : RECEIPT INTERFACE CONTRACTOR TBD - TO BE DETERMINED LIC ## 00096 COMPANY TBD - TO BE DETERMINED ADDRESS . . . . . . . . . . CITY/STATE/ZIP , TELEPHONE . . . . . . . . : FEE ID UNIT QUANTITY AMOU]4T PD-TO-DT THIS REC NEW BAL ------ ----- ----- ---------- ---------- ---------- BELEC200 METERS 1 .00 :29.43 0. 00 29.43 0. 00 BSEISMICRE VALUATION 500 .00 0.50 0 .00 0.50 . 0. 00 EPERMITFEE FLAT RATE 1.00 _38.37 0 .00 38 .37 0. 00 1;8. 30 0 .00 68 .30 0.00 TOTAL PERMIT ---------- ---------- METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----- --------------- -------------------- CHECK 68.30 1973 --------------- TOTAL RECEIPT 68 .30 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- ----- ------------- - --------------- 103 UFER 304 ROUGH ELECTRICAL 505 FINAL ELECTRICAL L-1-USA BEFORE ruu ui� -rou.. FREE 642-2444 y � r PWT PU.:iNS La Y l).kI` 5 �3 arm STUB FDR FUT R 9500 $Q Fr. i 400A SERVICE _ ..._... --._ D4 oTE -...� -, .. PZ A .1....�.P� o 0-4 STUB FnR FUTURE METER PEDESTAL roR WATER PUMP 100A SERVICE (160'.0') ... i'-r--�i- '�' UAL L�A.---1` � LOCATION 7 INSTALL 3' X 5' X 4'6' 1 V T PRt►�'Kr"tni%i.uwRc ~��'1- � / (TX OR 'J' MAY BE INSTALLED AT FUTURE DATE) BY Td563 *a.W* 0 Rco TD T-13116 ,r ht..l L BEFORL ruu uwA rol.i.. F r�EF 642-2444 �- i STUB FOR f UT RE 9500 SR FTf 400A SERVICE (25',0') Pit gy STUB FOR FUTURE •''''�� fl METER PEDESTAL FOR WATER PUMP 100A SERVICE r,/'_'� pAD (160'.0') 000 pA �. 14000 % LOCA TION 7 kfrf nc!IDC 1NJTALL -ink r. (TX OR 'J' MAY BE INSTALLED AT FUTURE DATE) T17 /to Rco _�0-27 3 TO T-13116'' A TLLLJ c Lij CITY OF CUPERTINO CUP TYOF © PERMIT APPLICATION FORM CPN# Date: :� 0 Mz z ��� Building Address: Mailing Address (if different from building address): z Z 1 7 5- f�>6L3©A Owner's Name: Phone#: 4 r440 &718 190 Contractor: - License : cC—L Cf2LulT CLEc-7QlL Contact: Phone: z{o q Cc( 1-3c.o7 Cupertino Business License#: v J Fax: Building Permit Info: t "J TN t- A-no(\i OF 10 0 Mv Pt)M (' ';7"-n0N Bldg ❑ Elect Plumb ❑ Mech ❑ Job Description- Residential Commercial ❑ Sq.Ft. Floor Area: �J ,+ Sq.Ft.: �t Cost of Project: Occupancy Group: ko U -�3 Type of Construction: Please check this box if the project is a zJ S16 L t-. UCS a.a^ AcKe-1 second-story addition: ❑ -'roject Size: Standard a Large ❑ Major ❑ �G�� C'c�✓i� Quantity Fee ID Fee Description Fee Group BAPPLOTHER Other Appliances MECHANICAL BBOILERI Boiler<_= 100,000 Btu MECHANICAL BBOILER2 Boiler> I OOK to 500K Btu MECHANICAL BBOILER3 Boiler> 5 DOK to 1 M Btu MECHANICAL BBOILER4 Boiler> 1M to 1.75 M Btu MECHANICAL BBOILER5 Boiler> 1.75M Btu MECHANICAL BCONSTAX Construction Tax BUILDING BCONSTAX Ind/Off/Zomm/Quasi BUILDING BCONSTAXBQ Con. Ta), for BQ Zone BUILDING BCONSTAXH Hotel and Motel BUILDING BCONSTAXR Constax--Resi/Mobile BUILDING BELEC 1000 Elec 60W <=-I OOOA ELECTRICAL BELEC1001 Elec 600V> IOOOA ELECTRICAL BELEC200 Elec Svcs 600V<=200A ELECTRICAL BENERGY Energy BUILDING BENERGYADD Energy Add Multi BUILDING BINVESTIGA Investigation fee BUILDING 1 of 3 CITY OF CUP'ERTINO CITY OF PERMIT APPLICATION FORM CUPEkTINO 7uantity Fee ID Fee Elescri tion Fee Group BREMSIGNAD Rmdl Signs Add Branch ELECTRICAL BREMSIGNS Remodel Soigns, Marquee ELECTRICAL BREMTHEATR Theatricd Lighting Fix ELECTRICAL BREMVENFAN Vent Fa.i Single Duct MECHANICAL BREMVENSYS Ventilation Systems, MECHANICAL BSCBLVD Scb Specific Plan BUILDING BSEISMICOM Seismic Commercial BUILDING BSEISMICRE Seismic Fee Res BUILDING BSPECIAL Special Inspection BUILDING BSWIM Swimming Pool BUILDING BTEMP Temporary Power ELECTRICAL BTEMPPERM Tempora -y Bldg Permit BUILDING BTEMPSVCS Temg Dist Svcs ELECTRICAL BUSLIC Business License BUILDING ELECTRIC Electr.cal sq foot ELECTRICAL EPERMITFEE Elec Permit Issuance ELECTRICAL Nit MPERMFEE Mechanical sq. foot MECHANICAL MPERMITFEE Mech Permit Issuance MECHANICAL PPERMITFEE Plumbin ; Permit Issue PLUMBING PPLBG Plumbing Fee sq foot PLUMBING PLLONGRNGC Planning LR C'omme/Multi-Faro PLANNING PLLONGRNGR Planning Long Range Residential PLANNING ZADDCHG Addre ss Change BUILDING 3 of 3