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12050168 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: I 1110 C14ADWICK PL CON I'll:\CToil:A L131R'IPF:Ralii No: 12050168 CONSTRUCTION OWNER'S NAME: DWIVEDI TARUN AND GAURI 2125 CABIULLO I-IWYS DAIS IssuEw05/22/2012 OWNEWS PUONE: 4082192952 HALT MOON BAY, CA 94019 I'll ONE No:(65u)241 9787 LICENSED CONTRACTOR'S DECLARATION r r r— nn BUILDING 14:R\II"1'INFO: BLDG F.I.l:CT PLUMII License Class7 _3 Lic H 4 )17'7 V r r r .UE(:11 RESIDE.N'I'IAL CM INIF:H(:IAL Conlmctor A l h c'/-f ('v+,i+Yu({�Ia:Datc 5 ?^+ 1 hereby affirm that 1 am licensed under the provisions of Chapter •JOB DLSCRIPTION''. 13A I'I IKOU•\I RIiTODLI.45 Sit;] (commencing with Section 7000)of Division 3 of the Business& Professions Code and that nry license is in Tull force and effect. I hereby affirm under penally of perjury ane of the following two declarations: I have and will maintain it cern icale of consent to self-insure liar Worker's Compensation,as provided Ibr by Section 3700 of the labor Code,for Ito perlornaance of the work Ibr which this permit is issued. Sq.Ft Floor Arta: Valuation:S3500 I have and will maintain Workers Compensation Insurance.as provided lin by Section 3700 ill Elie Labor Code.Ibr the pedormmnce of the work for which this :\I'N'Number: 1j617(183.0(1 Occupancy Type: pcnnil is issued. A PPLICAN'I'CFR'I'IF'IGVIION I certify that I have read this application and slave that the above inl6rntation is PERMIT EXPIRES IF WORK IS NOT STARTED correct, I agree a,caunph'with all city and county ordinances and stale laws relntin_ WITHIN 180 DAYS OF PERMIT ISSUANCE OR to building construction,and hereby authorize representatives ol'Ellis ciy to enter upon the above mentioned property for inspection purposes. (We.)agree to save 180 DAYS FROM LAST CALLED INSPECTION. indentnih.:tad keep haHaIe'SS the City of Cupertino against liabilities,judgments. costs,and expenses which nun'accrue against said City in consequence of tlic J . I 5-2-2 -12— granting of dais permil. Additionally,the applicant understands and will comply Issued by: l/V Bate: with u11 non-point Source regulations per the Cupertino Municipal Code,Section 9,18, ,( ,, RE-ROOFS: Signature ei�—� �� Dale S 'N/ /Z All roofs shall be inspected prior to any tooling material bring installed. 11 a rout'is installed without Irst obtaining an inspccuon. I agree it,rano%(all new materialh lin inspection. ❑ OWNER-BUILDER DECLARATION Si�_nalurc of Applicant: line hereby affirm Ihxt I:un exempt from the Conlractur's License 1.11. for one of the following two reasons: ALL ROOF CO\'ERINGS'10 ISE CLASS"V Olt BE ITER h as owner of the propene,or my emplo}'ces with wages as their sole compensation, will do the work,and[he structure is not intended or ollered for talc(Sec.7044. BusincSS&Professions(:olic) h as owner o1'[lie pmperty.:nn exclusively contracting with licensed contractors In IIA%.\RDOUS NI:\TERI.-\IS DISCLOSURE construct the project(Sec 704-4.13usiness&Pfafe)SIat1S Code), 1 little read the hazardnun materials n•quircmwo[s under Chapter 6.95 ul'tile California Health&Safety Code,Section,25505,25531 and 255341. 1 will 1 herrhv affirm under penalty of perjury'line of the following three maintain compliance with the Cupertino Municipal Code.Cbtgdcr'1.12 and the declarations: Ilealth&Salely Code.Section 25532(a)should I store or handle hazardous I have and will maintain it Cerlilicate of Canstnl to sell-insure Ibr Workers material. Additionally,should I use equipment lir devices which emit hazardous Compensation,as provided for by Section 3700 of the Labor Code,lou tile the air contaminants as defined by the Bay Area Air Quality Managenwmt District 1 performance ill tile work for which this permit is issued, will maintain compliance with the Cupertino Municipal(.ode Chapter 9.12 and I have and will maintain Worker's Compensation Insurance,as provided Ibr by the Ilcalth&Safely Code.Sections 255(15 25533.aa`25534. Section 3700 0l the Labor Code, lin die performance of the work for which this permit is issued. Owner or authorized ageal: Ihrte: J I certify 111.11 in the perhmnance of the work for which[his permit is issued,I shall not employ any person in any manner so as to become subject to the Worker's Compensation laws of Calitiunia. IL alter making this certificate of exemption,I CONS I'RU(I]ON LENDING AGENC 1' become subject to the P'orker's Compensation pnn'isions of the labor Code, I must I hcrchv a0irni that there is a construction Irndim_agenec Ibr the perlLnnanee ul forthwith comply with such provisions or this permit shat[be deemed revoked %work's hwrs,hich This pcnnil is issued(Sec. 3097.Cie C.) Lender's Name AITIX ANT(:HI(TIFICA"IION Lender's Address I eerily that I hm'c read this application and stale that the above in lomnal inn is correct. I agree to amtph with all cite and county ordinances and state laws relating to building C011SLRlFllan.and hereby'authorize representaincs of this city to cater upon the above mentioned property lot inspection purposes.(Wc)agree to sme :\ItClll'I'ICCI'S UF.CLAIt:\TION indemnit% and keep harmless due City of Cupertino against Iiabililics.judgalenls, costs.and expenses which any accrue against said City in consequence of LIlc I understand nw plans shall he used its public records. granting of this permit Additionaly,the applicant understands and will comply with all non-point source regdanons per the Cupertino Municipal Code.Section Licensed Professional 9.18, Signature Date CITY OF CUPERTINO 3 ITEMS OF 3 PERMIT RECEIPT OPERATOR: SylviaM COPY # 1 Sec : Twp: Rng: Sub: Blk: Lot : APN . . . . . . . . : 35617083 . 00 DATE ISSUED. . . . . . . : 05/22/2012 RECEIPT 4 . . . . . . . . . : BS000016879 REFERENCE ID # . . . : 12050168 SITE ADDRESS . . . . . : 11110 CHADWICK PL SUBDIVISION . . . . . . . CITY . . . . . . . . . . . . . : CUPERTINO IMPACT AREA . . . . . . . OWNER . . . . . . . . . . . . : DWIVEDI TARUN AND GAURI ADDRESS . . . . . . . . . . : 11110 CHADWICK PL CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM . . . . : ALBERT CONSTRUCTION CONTRACTOR . . . . . . . : ZHE LI LIC # 32824 COMPANY ALBERT CONSTRUCTION ADDRESS . . . . . . . . . . : 2125 CABRILLO HWY S CITY/STATE/ZIP . . . : HALF MOON BAY, CA 94019 TELEPHONE . . . . . . . . : FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL 1BCBSC VALUATION 3, 500 .00 1 . 00 0 . 00 1 . 00 0 . 00 1BSEISMICR VALUATION 3 , 500 . 00 0 . 50 0 . 00 0 . 50 0 . 00 1REMRESBAT SQ FEET 45 . 00 588 . 00 0 . 00 588 . 00 0 . 00 ---------- ---------- ---------- ---------- TOTAL PERMIT 589 . 50 0 . 00 589 . 50 0 . 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER --- - -- --- - ------- --------------- -------------------- CHECK 589 . 50 999994 ------------- -- TOTAL RECEIPT 589. 50 CITY OF CUPERTINO FEE ESTIMATOR- BUILDING DIVISION ADDRESS: 11110 Chadwick PI DATE: 05/22/2012 REVIEWED BY: Sean APN: BP#: 'VALUATION: 1$3,500 *PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration / Repair PRIMARY SFD or Duplex PENTAMATION 1R3SFDREM USE: PERMIT TYPE: WORK Remodel bathroom 45 sq ft SCOPE ,I h,ch. flan Check Plumb. Phu,Check lJee. Plan Gbcak Aleeh. l""mit Fere Plumb. Perini!Fre: lilec. Permit Fee: Odrer Hm h. Insp. Outer Plumb Insp. Other Elce.Inap. :Idsdi. LnP. (Le: Plumb. Imp. Fee Eler.Lisp. Fee: NOTE: This estimate does not includejees due to other Departments(Le Planning, Public Works,Fire,Sanitary Sewer District,School District,etc). Thesefees are based on the prelimina information available and are only an estimate Contact the De r or addn 7 info. FEE ITEMS (Fcc Resolution 11-053 EIC 711111) FEE QTY/FEE MISC ITEMS Plan Check Fee: $0.00 45 s.f. Remodel, Bath (<=300 sf) Suppl. PC Fee: Q Reg. 0 OT 0.0 his $0.00 $588.00 IREAMESBAT PME Plan Check: $0.00 Permit Fee: $0.00 Suppl. Insp. Fee@ Reg. 0 OT 0,0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 Con.etruclion T n. ildmini.vnvrive Fee.: 0 Work Without Permit? 0 Yes 0 No $0.00 Advanced Planning Fee: $0.00 Select a Non-Residential Travel Uocrunenlnlinn Fees: Building or Structure 0 Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item I31dg Stds Commission Fee: IBCBSC $1.00 j SUBTOTALS: $;1.50 $588.00 TOTAL FEE: 1 $589.50 c Revised: 04/01/2012 CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO,CA 95014-3255 CUPERTINO (408)777-3228• FAX(408)777-3333•buildina(o)cuoertino.orD EINEW CONSTRUCTION ❑ ADDITION ALTERATION/TI ❑ REVISION/DEFERRED ORIGINAL IIPPER7RMIT# O PROJECT ADDRESS /h/ Q lu P X(1 APN# �r r OWNER NAME PHONE E-M`AIL a '- IA�;v STREET ADDRESS CITY,STATE,ZIP - FAX CONTACT NAME A I PHONE E-MAIL STREET ADDRESS /-f �J CITY,STATE, ZIP FAX ❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT IIZCONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME / I 1S� G/ 'fin LICENSE NUMBER LICENSE TYPE BUS.LIC# ��Z 13 COMPANYNAME `{-J Y7 Z / E-MAIL p FAx C `�)- n e o-1 t �l e7<"ke u i if • Lo7*�STREET ADDRESS -2 Cwhrl MO H '^ / CITY,STATE,ZIP L A --n �j� PITONy ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC# COMPANY NAME E-MAIL FAY STREET ADDRESS CITY.STATE.ZIP PHONE DESCRIPTION OF WORK Y4"z4i; a S-F i -s EXISTING USE I PROPOSED USE CONSTR.TYPE I #STORIES /'. . USE TYPE OCC. SQ.FT. VALUATION(S) EXISTG NEW FLOOR DEMO TOTAL AREA AREA AREA NET AREA L 5 - BATHROOM / KITCHEN OTHER J REMODELAREA REMODEL AREA REMODEL AREA PORCHARFA DECKAREA TOTAL DECK/ RCH AREA GARAGE AREA: DETACH ATTACH #DWELLING WITS: IS A SECOND UNIT YES SECOND STORY ❑YES BEING ADDED? NO ADDITION? Y.7R0 PRE-APPLICATION J3 YES IF YES,PROVIDE COPY OF 15 THE BLDG AN YES BECEIV DBY: TOTAL VALUATION: -- PLANNLNGAPPLp 170 PIANNWG"PRO"-L LETTER EICHLER HOME? NO 3 By my signature below,I certify to each of the following: I am the property owner or authorized altent to act on the pnperty owner's behalf. 1 have maaddthis application and the information I have provided is correct. I 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 coon. 1 authorize representatives of Cupertino to enter the above-i/entified property for inspection purposes. �L � Z Signature of Applicant/Agent: /� Dale: / SUPPLEMENTAL INFORMATION REQUIRED PIAN CHECK TYPE ROUTING SLIP _New SFD or Multifamily dwellings: Apply for demolition permit forOVER-THE-COUNTER BUILDING PLAN REVIEW existing building(s). Demolition permit is required prior to issuance of building permit for new building. ❑ EXPRESS ❑ PLANNING PLAN REVIEW _Commercial Bldgs: Provide a completed Hazardous Materials Disclosure ElSTANIVARD ❑ PUBLIC WORKS form if any Hazardous Materials are being used as part of this project. ❑ LARGE ❑ FIRE DEPT _Copy of Planning Approval Letter or Meeting with Planning prior to ❑ MAJOR ❑ SANITARY SEWER Dlsraler submittal of Building Permit application. ❑ ENVIRONMENTAL HEALTH BldgApp_2011.doc revised 06121111 �1 _Y s i.,K O T" 6(<Iqp W4,'CrPYVO+ I r/le cp-m4*4 I D it-4 I,- r-pV I 6o f,2 CrPP a.9' Rew,0oP.Pf SIT Z tirlsh" A rpl('M4& COA-S, -Tayttn Dw:y 2 ato CBC ed,, klaR b-'Z, oo,;, ofiadsvfc/ ;Lofo Cec SUBMITTAL 2010 CF( V- FF —1 37- Z-Z� 7. Z-1- I iA 0 A 0 A 5CUPERTINO 1!ng Department r y ;I 2 2012 Fon 'I REVIEWEI ODE COMPLIANCE Reviewed By: -5- 22 /z I IIf 7a;,kn Divivedir 's bo.1lyoo-1 ",W ' aCwTW , dpA1l BY: -