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07050083 7777 CITY OF CUPERTINO < BUILDING DIVISION PERMIT � � TM�1cT�� ' .. BUILDI` Sfi D ESS: PERMIT NO. 1LEBANON DR TBD To BE DETERMINED 07050083 OWNER'S NAME: PERMIT ISSUE DATE PUSHPA KHATOD 05/10/2007 )NE: SANITARY NO. CONTROL NO. BUILDING PERMIT INFO ARCHITECTIENGINEER: BLDG ELECT PLUMB MECH L__J 10 Q LICENSED CONTRACTOR'S DECLARATION Job Description LU P I hereby affirm that I am licensed under provisions of Chapter 9(commencing Ey with Section 70(10)of Division 3 of the Business and Prof 'ons Codc,and my license is INSTALL AIR CONDITIONING, 2 UNITS >;y in full force andeff _2 Lien CONTRACTOR: FIRST AIR HEATING AND A/C SERVICES j n? License Class t—m Date Contractor ARCHrmcrs DECLARA ON 7 a< 1 understand my plans shall be used as public records )yU G0 y Licensed Professional OWNER-BUILDER DECLARATION 1 hereby affirm that I am exempt from the Contractor's License law for the pO following reason.(Section 7031.5,Business and Professions Code:Any city or county < which requires a permit to construct,alter,improve,demolish,or repair any structure Zy prior to its issuance.also requires the applicant for such permit to file a signed statement _ that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 iq.Ft. Floor Area Valuation uH$ (commencing with Section 7000)of Division 3 of the Business and Professions Code)or $63000 L that he is exempt therefrom and the basis for the alleged exemption.Any violation of Section 7031.5 by aapplicant for a permit subjects the applicant to a civil penalty of Q� Number Occupancy Type rty not more than five hundred dollars($500). 3421400 D:Z7 ❑I,as owner of the property,or my employees with wages as their sole compensation, will do the work,and the structure is not intended or offered for sae(Sec.7044.Easiness -Required Ins ectio ns and Professions Code:The Contractors License Law docs not apply to an owner of p property who builds or 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.). ❑1,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044.Business and Professions Code:)The Contractors Li- cense Law does not apply to an owner of property who builds or improves thereon,and who contracts for such projects with a contractor(s)licensed pursuant to the Contractors License Law. ❑I am exempt under See .B&P C for this reason Owner Date WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations: ave and will maintain a Certificate of Consent to self-insure for Workers Compen- sadon,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 Workers Compensation Insurance,as required by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. My Workers 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 for one hundred dollars($100) or less.) I certify that in thc perform f the work for which this permit is issued,I shall not employ any person in any j&to rs'Compensation Laws of California.Date Applicant NOTICE TO APPLICANT:If,aft m is Certificate of Exemption,you should become subject to the Workers Compensation provisions of the Labor Code,you must Oforthwith comply with such provisions or this permit shall be deemed revoked. Z, CONSTRUCTION LENDING AGENCY r/. 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.C.) WGti.A Lender's Name Z Lenders Address U C—) 1 certify that I have read this application and state that the above information is L4 r d correct.I agree to comply with all city and county ordinances and state laws relating to (DVbuilding construction.and hereby authorize representatives of this city to enter upon the a above-mentioned property for inspection purposes. (We)agree to save,indemnify and keep harmless the City of Cupertino against „d Cil liabilities,judgments,costs and expenses which may in any way accrue against said City r `/ U Z in consequence of the granting of this permit. Date �. APPLICANT UNDERSTANDS AND WILL PLY TH ALL NON-POINT Issued by: E REGULATIONS. S_ �(a Ga—� Re-roofs!Mj <�1� nature of Appli, nt w1r Dite Type of Roof HAZARDOUS dA ALS DISCLOSURE Will the applicant or Tutu uilding 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 ;hall be inspected prior to any roofing material being installed. ❑Yes Will the applicant or future building occupant use equipment or devices which If a roof i.;installed without first obtaining an inspection,I agree to remove - emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection. District? ❑Yes GING— I have read the hazardous materials requirements under Chapter 6.95 of the Califor- nia Health&Safety Cade,Sections 25505,25533 and 25534.I understand that if the building does not curendy have a tenant,that it is my res ;hilit a notify the occupant of thc =!!r. hich must be met prior a iss u care oroccupancy. Signature of Applicant Date Z� All roof coverings to be Class"B"or better O or authorized agent CITY OF CUPERTINO 7 ITEMS OF 7 PERMIT RECEIPT OPERATOR: suew COPY # 1 Sec: Twp: Rng: Sub: Blk : Lot: APN . . . . . . . . : 34214005.00 DATE ISSUED. . . . . . . : 05/10/2007 RECEIPT #. . . . . . . . . : BS000001271 REFERENCE ID # . . . : 07050083 SITE ADDRESS . . . . . : 10141 LEBANON DR SUBDIVISION . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . OWNER PUSHPA KHATOD ADDRESS . . . . . . . . . . . CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-2645 RECEIVED FROM . . . . : RECEIPT INTERFACE CONTRACTOR . . . . . . . : TBE - TO BE DETERMINED LIC # 00096 COMPANY TBE - TO BE DETERMINED ADDRESS . . . . . . . . . . CITY/STATE/ZIP . . . : , TELEPHONE . . . . . . . . : FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- ---------- BENERGY PERMIT FEE 1 .00 34 .86 0 .00 34 .86 0. 00 BREMAIRHAN NO.UNITS 2 .00 20.52 0 .00 20 .52 0. 00 BSEISMICRE VALUATION 63, 000 .00 6.30 0 . 00 6 .30 0.00 BUSLIC FLAT RATE 1.00 107.00 0 . 00 107. 00 0. 00 EPERMITFEE FLAT RATE 1. 00 38 .37 0 . 00 38 .37 0. 00 MPERMITFEE FLAT RATE 1 . 00 38 .37 0 . 00 38 .37 0 . 00 PPERMITFEE FLAT RATE 1 . 00 38 .37 0 . 00 38 .37 0.00 ---------- ---------- ---------- ---------- TOTAL PERMIT 283 .79 0 .00 283 . 79 0. 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CHECK 283 . 79 1025 --------------- TOTAL RECEIPT 283 .79 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 204 UNDERFLOOR FRAME 301 ROUGH PLUMBING 303 ROUGH MECHANICAL 304 ROUGH ELECTRICAL 505 FINAL ELECTRICAL 507 FINAL PLUMBING 508 FINAL MECHANICAL 514 FINAL PUBLIC WORKS CITY OF CUPERTINO 7 ITEMS OF 7 PERMIT RECEIPT OPERATOR: suew COPY # 1 Sec: Twp: Rng: Sub: Blk:: Lot: APN . . . . . . . . : 3414005 . 00 DATE ISSUED. . . . . . . : 05/ 10/2007 RECEIPT #. . . . . . . . . BSC00001271 REFERENCE ID # . . . 07C50083 SITE ADDRESS . . . . . : 10141 LEBANON DR SUBDIVISION . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . OWNER PU.cHPA KHATOD ADDRESS . . . . . . . . . . CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-2645 RECEIVED FROM . . . . : REC'EIPT INTERFACE CONTRACTOR . . . . . . . : TBI - TO BE DETERMINED LIC # 00096 COMPANY . . . . . . . . . . : TBI - TO BE DETERMINED ADDRESS . . . . . . . . . . : CITY/STATE/ZIP . . . : , TELEPHONE . . . . . . . . : FEE ID UNIT QUANTITY I.MOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- -- -------- ---------- ---------- ---------- BENERGY PERMIT FEE 1 . 00 34 .86 0 .00 34 .86 0.00 BREMAIRHAN NO.UNITS 2 . 00 20 .52 0 .00 20 .52 0 .00 BSEISMICRE VALUATION 63, 000. 00 6 .30 0 . 00 6 .30 0 .00 BUSLIC FLAT RATE 1 . 00 107.00 0 . 00 107 . 00 0 .00 EPERMITFEE FLAT RATE 1 .00 38 .37 0 . 00 38 .37 0 . 00 MPERMITFEE FLAT RATE 1 .00 38 .37 0 .00 38 .37 0.00 PPERMITFEE FLAT RATE 1 .00 38 .37 0 . 00 38 .37 0. 00 -- -------- ---------- ---------- ---------- TOTAL PERMIT 283 . 79 0 .00 283 . 79 0. 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CHECK 283 .79 1025 --------------- TOTAL RECEIPT 283 . 79 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 204 UNDERFLOOR FRAME 301 ROUGH PLUMBING 303 ROUGH MECHANICAL 304 ROUGH ELECTRICAL 505 FINAL ELECTRICAL 507 FINAL PLUMBING 508 FINAL MECHANICAL 514 FINAL PUBLIC WORKS CITY OF CUPERTINO � tso yTR1J CfA ; CUPEI�TINO PERMIT APPLICATION FORM -.?N # Date: Building Address: lVo A— ��'/ Owner's Name: Phone#:k4v Li� Contact: , � / Phone: .-,V�— � Z� Cupertino Business License#: Building Permit Info: Bldg ❑ Elect Plumb El" Mech L� Job Description. A4 12 Ln Residential Commercial ❑ For Rei 6nitial.Installations: Attic I' floor El 2nd floor ^/ Adhere to min set back requirement E S For Commercial Installations: placement same weight ❑ Additional weight (strzctural calcs) ❑ structural Calculations required for new installation 11 New installation Planning Approval Required ❑ Cost of Project: / Type of Construction: _ 6 av Occupanc group: b r �b O .`" `� � Strapped ElOn Platform Bonded L Sq.Ft. Floor Area: �— New Location Replacement f i Qty. Applicable f Fee ID Fee Description Fee Group BENERGY En,-rgy BUILDING BREMFURN Funace MECHANICAL BREMACOVER A/' Unit> 10,000 cfm MECHANICAL gREMpIRHAN A/, Units <= 10, 000 cfrn MECHANICAL BREMRECEPT Recptl, Switch& Outlets ELECTRICAL BSEISMICRE Seismic Fee Res BUILDING BSEISMICOM Seismic Commercial BUILIDNG EPERMITFEE Eloc Permit Issuance ELECTRICAL MPERMITFEE Moch Permit Issuance MECHANICAL PPERMITFEE Plumbing Permit Issue PLUMBING BPERMFEE Brig Permit Fees BUILDING BPLANCHK Plim Check Fee BUILDING BPGAS ' GEs Piping System Fee PLUMBING BUSLIC Bi:siness License BUILDING 10300 TORRE AVENUE ACCOUNT# CUPERTINO,CA 95014-3255 TEL(408)777=3221 FAX(408)777-3109 NEWCITY OF CUPERTINO BUSINESS LICI?NSE APPLICATION RENEWAL AME OF BUSINESS LOCATION OF BUSINESS T STREEr ADDRESS e V22- 37M 64N- / 6 3 � PHONE( )V CITY STATE ZIl' MAILING ADDRESS IF DIFFERENT THAN ABOVE NATURE OF BUSINESS , �2.�) 2 �-I l S-7 r tiUURS OF OPERATION IF YOU ARE OPERATING AN APARTMENT COMPLEX, PLEASE STATE NUMBER OF UNITS SQUARE FOOTAGE OF YOUR BUILDING SPACE IN CUPERTINO � LEGAL STATUS OF BUSINESS CORPORATION PARTNERSHIP SOLE PROPRIETOR START DATE OF BUSINESS IN CUPERTINO–(MONTHIMf Y/YEAR) STATE EMPLOYER ID NO. � b 6 / C' FEDERAL TAX ID NO. 7 U / �d STATE BOARD OF EQUALIZATION TAX NUMBERA 3- .jWNER/OFFICER NAMES //9 /' l DRIVER LICENSE# 1�yTATE� PHONE(VX) ' STREET ADDRESS CITYPSTATE/ZIP OWNER/OFFICER NAME DRIVER LICENSE# STATE PHONE ( ) STREET ADDRESS CITY/;;TATE/ZIP OWNER/OFFICER NAME DRIVER LICENSE# STATE PHONE( ) STREET ADDRESS CITY/,STATE/ZIP *HOME BUSINESS APPLICANTS PLEASE COMPLETE REVERSE SIDE* TO THE BEST OF MY KNOWLEDGE,THE ABOVE INFORMATION IS TRUE AND CORRECT. I AM AWARE THAT SOME OF THE INFORMATION IS AVAILABLE TO THE PUBLIC. APPLICANT'S SIGNAtM DATE FOR OFFICE USE ONLY ZONING APPROVAL _ DATE APPROVED DATE PROCESSED RECEIPT NUMBER AMOUNT INITIALS Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone(408)777-3228 CM OF Fax(408)777-3333 flPEkTINO Building Department JOB ADDESSZ"ep PERMIT# l ng-7 1)4 -70So 0 d"--7 OWNER'S NAME: E C&S /g- , PHONE# Y Z,-Z— GENERAL CONTRACTOR: FAX# 2 - 4"-? 20 I am not using any subcontractors: Si,mature 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 Ornamental Sheet Metal Painting/ Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile 0 w n e r/C o n1rac rI 7�' e Date