12070080 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 7494 SHADOWHILL LN CONTRACTOR:PELLE HEATING&AC PERMIT NO: 12070080
INC
OWNER'S NANIE: RA11V&ANIALI DESHMUKH 3728 C CHARTER PARK DR DATE ISSUED:07/112012
OWNER'S PHONE: 4086236712 SAN JOSE,CA 95136 PHONE NO:(408)978-7060
❑ 1LI�CENSSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL COMMERCIAL
License Class
�s e� f Lic.N �q�� p��y ADD A/C UNIT
Conlmclor,j i,—t I ` 1 ' f f 1l rDale t I 271
1 hereby alarm that 1 am licensed under the provisions of Chapter 9
(commencingwith Section 7000)of Division 3 of the Business&Professions
Code and that my license is in full force and effect.
I 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 whichlhis permit is issued. Sq.Ft Floor Area: Valuation:$4450
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.36230096.00 Occupancy Type:
permit is issued.
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED
correct.l 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 mentiahed property for inspection purposes.:(We)agree to save 180 DAYSM 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 Date:
// I •z
granting of this pernit. Additionally,the applicant understands and will comply Issued by: 7c^
G
with all non-point source regulations per.the Cupertino Municipal Code,Section
Date --1I 12-0/2— RE-ROOFS:
Signature C I�I�(�Y'C/V)/vAll 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
inspection.
❑ OWNER-BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License Law for one of Signature of Applicant: Date:
the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
1,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& Prolissions Code)
I,as owner of the property,am exclusively contracting with licensed contractors to IIA'/-ARDOUS NIATERIA S DISCLOSURE
construct the project(Sec.7044,Business.&Professions Code). 1 have read the hazardous materials requirements under Chapler 6.95 of the
California Health&Safely 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: Health&Safety Code,Section 25532(a)should 1 store or handle hazardous
1 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 I
performance of the work for whichthis permit is issued. will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safet Code Sections 255051 25533,and 25534•
Section 3700 of the Labor Code,for the performance of the work for which this. 12-101
Owner or authorized again • Dale:
permit is issued.
I certify that in the performance of the work for which this permit is issued,I shall
not employ any person in any manner so as to become subject to the Worker's CONSTRUCTION LENDING AGENCY
Compensation laws of California. If,alter making this certificate of exemption,I
become subject to the Workers Compensation provisions of the Labor Code,I 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. work's for which this permit is issued(Sec.3097,Civ C.)
Lender's Name
APPLICANT CERTIFICATION Lender's Address
I cenify that I have read this application and state that the above information is
cored.1 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
GENERAL PERMIT APPLICATION �o P
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 ^ V
CUPERTINO (408)777-3228•FAX(408)777-3333•buildinO cDcuper inG.orgmisc
PLUMBING 4MECHANICAL ®ELECTRICAL ❑/MISCE'LLANE'OUS
PROJECTADDRESS q C 1 , 11 � APNn � l0� C) (C16
OWNER NAME j2 KJ be PHONE
V r`PHONE '^ '�t l� EC-MAIL lJ V {{{
STREET ADDRESS Jr,_ _.1 r x•`11 CITY, STATE.ZIP VJ FAX
CONTACT NAME ■� H PHONE E-MgIL
I� S 1OlQ hk�..tOCI �C ae f
STREET ADDRESS CIN.STATE ZIP `, ^ FAX G,4 I,
921C
11 OWNER ❑ OWNER-BUILDER 11OWNERAGENT CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER o❑TENANT
CONTRACTOR NAMEt / LICENSE NUMBER 1 LICENSE TYPE BUS LIC a elk
Z7 3
COMP N AME F.-MAIL FAX l
r' . ��Iltilw X108 ( 7"o
STREET ADDRE�SO G.- /�; r 1 CRY.STATE,21P � Cf+ hs�3-v PHONE li
7 -17810 bD
ARCHITECT/ENGINEER NAME �-�T LICENSENUMBER BUS LICM
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY.STATE.ZIP PHONE
USE OF ❑SFDnr DUPLEX ❑ MULTI-FAMILY PROJECTIN WILDLAND ❑ YES PROJECT IN ❑ YES ISTHEOLOG AN ❑ YES
BUILDING'. ❑COMMERCIAL URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑ NO EIC14UR HOME? ❑ NO
DESCRIPTIONOF WORK
16-
TOTAL
'✓ •6-
TOTAL VALUATION: y� y VO RECEIVED BY:
By my signature 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 I have provided is correct. 1 have read the Description of Work and verify it is accurate. I agree to comply With all applicable local
ordinances and stele laws relating to builcyng,construction I autbprize representatives of Cupertino to enter the above-identified property for inspection purposes.
Signature of Applicant/AgenT. Date'.
SUPPLEMENTAL INFORMATION REQUIRED -
oRFicEuseoivLrr_�
OVER-THF COUNTER ;i.:. ',•�
1' ❑ EXPRESS :~.
� ❑ STANDARD
❑ LARGE'- _:.
"❑.MAJOR lw1�6'rt .S ;ti'•„
A1FPMiscApp_201 1.doc revised 06121/11
CITY OF CUPERTINO
FEE ESTIMATOR— BUILDING DIVISION
ADDRESS:_10697,rosewood rd AB;C,D, DATE: 07/11/2012 REVIEWED BY: bobs.
APN: ,� BP#: 'VALUATION: $28,000
*PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration / Repair
PRIMARY SFD Or Du IBX PENTAMATION 1R3SFDREM
USE: p PERMIT TYPE: Al
WORK Apt. complex-remodel kitchen add laundry room.
SCOPE
Meeh. Plan Cheek 0.0 hrs $0.00 Plumb. Pian Check Elev. Plrn,Chrrk
Mech. Permi[Fee: IMPERMIT /'lamb. Pc,mil Fra: EFr. Pe, Fo.::
Other Mech.lnsp. 0.0 hrs $45.00 011ier Plumb ln.rp, LLJ Urhrr liicr. Lsp.
,Wcrh. In,p. Fcf- Plumb. besp.Fee: lilef. bap. Fec:
NOTE: This estimate does not includejees due to other Departments(Le.Planning,Public Works, Fire,Sanitary Sewer District,School
District,etc. . These fiTs are based on the prelimina information available and are only an estimate. Contact fire De 1 or addn'l info.
FEE ITEMS (Fee Resohuion 11-053 Eff. 711111) FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 160 s.f. Remodel, Kitchen (<=300 sf)
Suppl. PC Fee: Q Reg. O OT FO.0 hrs $0.00 $600.00 IREMRESKIT
PME Plan Check: $0.00 120 s.f. Remodel, Bath (<=300 sf)
Permit Fee: Hourly Only? OYes 0 No $0.00 $600.00 IREAIRESBAT
Suppl. Insp. Fee Q Reg. OOTFO-01 hrs $0.00 = # Mechanical
PME Unit Fee: $0.00 $134.00 IBAPPLOT Other Appliance/Equip
PME Permit Fee: $45.00
Conslrurtion Ta.r:
Administrative Fee: IADM/N $42.00 O
Work Without Permit? O Yes (F) No $0.00 E)
Advanced Planning Fee: $0.00 6 hours Inspections E)
Travel Documentation Fee: 1TRAVDOC $45.00 $798.00 ISTINSP Inspection, Hourly 0
StronE Motion Fee: IBSEISMICR $2.80 Select an Administrative Item
Bldg Sids Commission Fee: IBCBSC $2.00
{ , , SUBTOTALS: $136.801$2,132.001 TOTAL FEE: $2,268.80
Revised: 07/01/2012