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12050131 CITY OF CUPERTINO BUILDING PERMIT BILI LDING ADDRESS: 20930 FARGO DR CONTRACTOR:SIGURA PERAIIT NO: 12050131 CONSTRUCTION INC OWNER'S NAIVE: SUNII.E SHRIVASTAVA 614 NATIONAL AVE DATE ISSUED:05/162012 OWNER'S PIIONE: 6503918451 MOUNTAIN VIEW,CA 94043 PHONE NO:(408)736-7952 LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL 11 COMMERCIAL❑ License Class �G `l�J Lic.n (JJ5) 55 TEMPPOWER Comrucmr ]LLll�j , 1 �I,l1Gl, Dale /(1 IZ 1 hereby affirm that I am licensed under the provisions of Chapter 9 (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 penally 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 Arca: Valuation:$500 1 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 / � APN Number:32630113-00 Occupancy Type: permit is issued. APPLICANT CERTIFICATION [0 I certify that I have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED correct. I agree to comply with all city and county ordinances and state laws relating WITHIN 180 DAYS OF PERMIT ISSUANCE OR to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We)agree to save 180 DAY FROM LAST CALLED INSPECTION. indemnify and keep harmless the City of Cupertino against liabilities,judgments. costs,and expenses which may accrue against said City in consequence of the granting of this permit_ Additionally,the applicant understands and will comply Issued by: /' 7 Date; �(O with all non-point source regulons per the Cupertino Municipal Code,Section 1 f n RF.-ROOFS: Signature Dale L All roofs shall be inspected prior m any tooling material being installed. If a roof is installed without first obtaining an inspection,I agree to remove all new materials for inspection. ❑ OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Lew for one of Signature of ApplicanL Date: the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER 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 sale(Sec.7044. Business&Professions Code) 1,as owner of the property.am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE construct the project(Sec.7044,Business&Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the California Ileahh&Safety Code,Sections 25505,25533,and 25534. 1 will I hereby affirm under penally of perjury one of the following three maintain compliance with the Cupertino Municipal Code.Chapter 9.12 and the declarations: Ilealth&Safety Code.Section 25532(x)should 1 store or handle hazardous I have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally,should I use equipment or devices which emit hazardous Compensation,as provided for by Section 3700 of the Labor Code,for the air contaminants as defined by the Bay Area Air Quality Management District performance of the work Ibr which this permit is issued. will maintain compliance with the Cupertin (hlunicipal Code,Chapter 9.12 and I have and will maintain Worker's Compensation Insurance,as provided for by the I Ica11h&Safety Code,Sec[ as 25505, 55333,a Id 25534. G� Section 3700 of the Labor Code,for the performance of the work for which this r 1 Date.-5 ' Z permit is issued. Owner or authorized egen 1 certify that in the performance of the work for which this permit is issued,1 shall not employ any person in any manner so as to become subject to the Worker's Compensation laws of California, If,after making this certificate of exemption,I CONSTRUCTION LENDING AGF.NCV become subject to the Worker's Compensation provisions of the Labor Code,1 must I hereby affirm that there is a construction lending agency for the performance of forthwith comply with such provisions or this permit shall be deemed revoked. w'ork's for which this permit is issued(Sec,3097,Civ C.) Lender's Name APPLICANT CERTIFICATION Lender's Address 1 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 state laws relating to building construction,and hereby authorize representatives of this city to enter 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 1 understand my plans shall be used as public records_ granting of this permit.Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code,Section Licensed Professional 9.18. Signature Date CITY OF CUPERTINO FEE ESTIMATOR — BUILDING DIVISION ADDRESS: 20930 FARGO DR DATE: 05/16/2012 REVIEWED BY: Sylvia APN: BP#: 'VALUATION: $500 PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration / Repair PRIMARY SFD or Duplex PENTAMATION 1REAP14 USE: PERMIT TYPE: Al WORK Temp Power SCOPE ,th,ch. Plan C'herk Phnnh. Plop ChexElec. Plan Check 0.0 hrs $0.00 !lrrh. Permit Poo: Mwnh. Po mil Pec: Elec. Permit Fee: IEPERAIIT fAhrr.1h"h. bvp. Usher I4rnnh Imp. Other Elea Insp. 0.0 hrs $44.00 d6rh. ln.,p. Fe'! P/l.mh. lnxp. l4'e: tiler. /mp. Frc: NOTE: This estimate does not includejees due to other Departments(i.e. Planning,Public (Forks, Fire,Sanitary Sewer District,School District,eta). These fees are based on the prelimina information available and are only an estimate. Contact lite Dept for mldn 7 info. FEE ITEMS(Fee Resohuion I1-053 Efl. 71111 U FEE QTY/FEE MISC ITEMS Plan Check Fee: $0.00 200 amps Electrical Suppl. PC Fee: Q Reg. Q OT F0,0Thrs $0.00 $44.00 IERT<200 I Temporary Power PME Plan Check: $0.00 Permit Fee: $0.00 Suppl. Insp. Fee:Q Reg. Q OT 0,0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $44.00 C'uns/ra(dun Tu.c• Administrative Fee: (ADMIN $41.00 0 Work Without Permit? O Yes (E) No $0,00 G) Advanced Planning Fee: $0.00 Select a Non-Residential Q or Structure Travel Documentation Fee: ITRAVDoc $44.00 Building A Strong Motion rce: IBSEISMICR $0.50 Select an Administrative Item Bide,Slds Commission Fee: IBCBSC $1.00 SUBTOTALS: 1 $130.50 $44.001 TOTAL FEE: $174.50 Revised: 04/01/2012 CITY OF CUPERTINO 6 ITEMS OF 6. PERMIT RECEIPT OPERATOR: counter COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN . . . . . . . . : 32630113 . 00 DATE ISSUED. . . . . . . : 05/16/2012 RECEIPT #. . . . . . . . . BS000016835 REFERENCE ID # . . . : 12050131 SITE ADDRESS . . . . . : 20930 FARGO DR SUBDIVISION . . . . . . . CITY . . . . . . . . . . . . . : CUPERTINO IMPACT AREA . . . . . . . OWNER . . . . . . . . . . . . : SUNIL K SHRIVASTAVA ADDRESS . . . . . . . . . . : 20930 FARGO DR CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM . . . . : SIGURA CONSTRUCTION CONTRACTOR . . . . . . . : ILAN SIGURA LIC # 28892 COMPANY . . . . . . . . . . : SIGURA CONSTRUCTION INC ADDRESS . . . . . . . . . . : 614 NATIONAL AVE CITY/STATE/ZIP . . . : MOUNTAIN VIEW, CA .94043 TELEPHONE . . . . . . . . : (408) 736-7952 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 AMOUNT REFERENCE NUMBER --------------- --------- ----------- CREDIT CARD 174 .50 visa --------------- TOTAL RECEIPT 174 . 50 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ------- -- ------------------- 402 TEMPORARY POWER GENERAL.PERMIT APPLICATION MEP COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 m Isc CUPERTINO (408)777-3228•FAX(408)777-3333• buildina(a)cupertino.orD � PLUMBING MECHANICAL ELECTRICAL MISCELLANEOUS PROJECTADDRESS\\' IZ 3V afg C)) CVV/ APN9 pq• /{ /1 OWNER NAME l`A11 _PHItO � 'V 151U/ EMAIL STREET ADDRESS 'CITY.STATE,ZIP �1 FA% CONTACTNAME PHONE ` 1 IV E-MAIL STREET ADDRESS CITY,STATE, ZIP FAX ❑OWNER ❑ OWT'ER-BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT CO. C1AI�,NAME(S; ` \ - .LICLT$E]v E {5 L 5 Ty,PE -� BUS.LICK COMPANYIpNpAAM1 E , .;}�r'�t V�`//� /�O�n<}t/J T/'}r ryiV SEE-MAIL J ' FAX STRE Al 1 5 a IIVLn lull `� .ILJI I Vtl.1 Lln I r _ I . 9 �tiv�.v iPwl CA -*qu 13 PHONE ARCHITECTIENGINEFR NAME LICENSE NUMJBER BUS.LIC A COMPANY NAMEEMAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE USE OF ❑SFD or DUPLEX ❑ muun- AAfILY PROJECT IN W ILDLANU ❑ NTS PROJECT W ❑N Es IS THE BLDG AN ❑YES BUILDING COMMERCIAL URBAN NTERFACE AREA ❑ NO FLOOD ZONR ❑NO EICHLER HOME? ❑NO DESCRIPTION OF WORK TOTALVALUATION: ! �VV -VV RECEIVED BY: By my signature below,1 certify to each of the followm : I am the property owner or authorized agent to act on the property owner's behalf. 1 have read this application and the information 1 have provided is car . I have read the Description of Work and verify it is accurate. 1 agree to comply with all applicable local ordinances and state laws mlatinf t uilding cons on. I a throne representatives of Cupertino to enter the above dem f7id p�r7operty for inspection puiposes. Signature of ApplicanVAgent: V Date: J I�I/l( L SUPPLE AL INFORMATION REQUIRED CE USE ONLY OL"ER-TILE-COUNTER ❑ EXPRESS U U ❑ STANDARD U ❑ LARGE L ❑ NIMOR A9EPMiscApp_2011.doc revised 06/21/11