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12070111CITY OF CUPERTINO BUILDING PERMIT RUILDINGADDRESS: 10256 GLENCOE DR CONTRACTOR:' JERM[TNO:12070111 OSS'NER'S N,\SIE: VENKATARAMAN SIIIVAKUMAND ADINIO �nyAR ��ST 1�• k--i—`` DA'I'S ISSUED:07/162012 OWNER'S P1 ON E: 4086549620 PHONE NO: ❑ LICENSED CON-rRACFOR'S DECLARATION •C BUILDING PFRSII'P INFO: BLDG r Ii1.liCT'r PLUSIB r License Class t3 ` Lie. .3 C -1 _tf iL r r r . MECH RESIDENTIAL COMMERCIAL Contractor ['}rh �% 1 �I�-y�` Date / 1�11 Ito lC[ I b t Z hereby affirm that I am licensed under the provisions of Chapter 99 JOB DESCRIPTION: TEMP POWER POLE (commencing with Section 7000) of Division 3 of the Business & Professions Code and that nn• license is in full force and effect. hereby affirm under penalty of perjury one of the following two declarations: I have and will maintain a ccrtilicme ofconsent 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 Ellis permit is issued. Sq, Ft Floor Area: Valuation: $500 I have and will maintain Worker's Compensation Insurance, as provided for be Section 3700 of the Labor Code, for the perfomrance of the work for which this permit is issued. APN Number: 32630029.00 OccupancyType: .U'I'LIC,\N'1' Clilfl'I FIC.CI'ION I certify that 1 have read this application laid state that the above information is correct. I agrto comply with all city and county ordinances and state Imes relating wee to building consction, and hereby authorize representatives of this city to enter PERMIT EXPIRES IF WORK IS NOT STARTED upon the above mentioned property for inspection purposes. (We) agree to save indemnify and keep harndesstile City ofCupeninoagainstliabilities, judgments, WITHIN 180 DAYS OF PERMIT ISSUANCE OR costs, and expenses which may accmcagainst said City in consequence of the Igp PAYS FROM LAST CALLED INSPECTION. granting of this permit. Additionally, the applicant understands and will comply with all non -point source regulations per the Cu Lino Municipal Code, Section 9.18. �J / Issued by:%"" Darr. Signau c �- Date ❑ OWNER -BUILDER DECLARA'T'ION RI ROOFS: All roofs shall be inspected prior to any roofing material being installed. If a roof is hereby aDfnn that I am evengt from the Contractor's License Law for one of installed without First obtaining an inspection, I agree to remove all new materials for the following mo reasons: inspection. I, as owner of the property, or nay employees with wages as their sole conllinsat ion, will do the work :ted the structure is not intended or offered far sale (Sec.7044, Signature ol'Applicne Date: Business & Professions Code) I, as owner of the property, am ecclusicely contracting with licensed contractors to construct the project (Sec.7044, 13usiness & Professions Code). ALL ROOT' COVERINGS TO, BE CLASS "A" OR BE ITER hereby affirm under penalty of perjury line of the following three declarations: IIAZARDOUSMATERIA SDISCLOSURE I have and will maintain a Certificate of Consent to self -insure for Worker's I hire read the hazardous materials requirements under Chapter 6.95 of the Compensation, as provided for by Section 3700 of the Labor Code, for the California I Icalth & Safety Code Sections 2.5505. 25533, and 25534. 1 will maintain performance of the work for which this perniit is issued. compliance with the Cupertino Slu nici pal Code. Chapter 9.12 and (lie Health & I have and will maintain Worker's Compensation Insurance, as provided for by Safety Code. Section 2553:(x) should I store or handle hazardous material. Section 3700 of the Labor Code, for the perl'ormanee of the work for which this Addiliunalh., south] I use equipment or devices which emit hazardous air permit is issued, contaminants as defined by the Bay Area Air Quality Management District 1 will maintain compliance with the Cupertino Slunicipal Code, Chapter 9.12 and the I certify that in the perfomrance ol'dae work lonvhich this permit is issued, l shall Health & Safety Code, Sections I .05. 25533. and 25534. not employ any person in way manner so as to become subject to the Worker's Compensation laws of Cnlifornia.If, alter making this certificate of exemption. 1 honer ora ¢ agent: ` become subject to the Worker's Compensation provisions of the Labor Code, I must a Uutc forthwith comply with such provisions or this pemnit shall be deemed revoked. CONSTRUCTION LENDING AGENCY \I'1'LIC.y\ I' CP:R'1'IPIG\"PION I hereby affimr that there is a construction lending agency for the performance of work's I certify that I have read this application and state that the above information is for which this Permit is issued (Sec. 3097, Civ C.) correct. 1 agree to comply with all city and county ordinances and state laws relating Lender's Name to building construction, and hereby authorize representatives of this city to enter upon One above mentioned property for inspection purposes. (We) agree to save Lender's Address indemnify and keep harmless the Cit' of Cupertino against liabilities, judgments, costs, and expenses which may accrue against said Cit in consequence of the granting of this permit. Additionally, the applicant understands and will comply ARCUrrEC^S DECLARATION with all non -point sconce regulations per the Cupertino Municipal Code, SectiOu I understand my plans shall be used as public records. 9.18. Licensed Professional Signature Date F& ��W��///� CITY OF CUPERTINO MR FEE ESTIMATOR—BUILDING DIVISION gFDDRFSS: 10256 9lencoe DATE: 07/16/2012 REVIEWED BY: bob s. UNITS APN: BP#: 'VALUATION: $500 *PERMITTYPE: Electrical Permit PLAN CIIECK TYPE: Alteration / Addition / Repair PRIMARY SFD or Duplex USE: Amps PEPENTANIATION 1REAP1 RMITTYPE: i WORK temp power pole SCOPE Suppl. Insp Fee APPLIANCE / EQUIP TYPE FEE ID Plumb. Plan Check QTY UNITS BP FEES Elec. Permit Fee: /EPERAIIT Temporary Power 1ERTQ00 Other Elea Insp. 0.0 hrs $45.00 200 Amps $45 Permit Fee: Suppl. Insp Fee PME Unit Fee: $45.00 PME Permit Fee: $45.00 Consu•uction Tax: Administrative Fee: 1ADAHN $42.00 Work Without Permit? O Yes Q No $0.00 TOTALS: A Travel Documentation Fee: ITRA VDOC $45.00 Strong. Motion Fee IBSEISAHCR NOTE.: This estinmte doev not include jeev due to other Departments (i.e. Planning, Public IVorks, Fire, Sanitary Sewer District, School District. etc.). These fees are based on the preliutinarr information aealhtble and are ott4, an estimate Contact the Dept for at/dn7 info. FEE ITEMS (Fee Resolution 11-053 Eft, 7/1/11) Meclt. Plan Check I I Plumb. Plan Check Elec. Plan Check 0.0 1 hrs $0.00 Alech. Permit Fee: Plumb. Permit Fee: Elec. Permit Fee: /EPERAIIT Other Atech. Insp. Other Phonh Insp,Ll I Other Elea Insp. 0.0 hrs $45.00 A/ach. hup. Fee: Plmnh. hup. Fee: Elec. Insp. Fee: NOTE.: This estinmte doev not include jeev due to other Departments (i.e. Planning, Public IVorks, Fire, Sanitary Sewer District, School District. etc.). These fees are based on the preliutinarr information aealhtble and are ott4, an estimate Contact the Dept for at/dn7 info. FEE ITEMS (Fee Resolution 11-053 Eft, 7/1/11) FEE QTY/FEE MISC ITEMS Plan Chick bee: suppl. PC ree PME Plan Check: $0.00 Permit Fee: Suppl. Insp Fee PME Unit Fee: $45.00 PME Permit Fee: $45.00 Consu•uction Tax: Administrative Fee: 1ADAHN $42.00 Work Without Permit? O Yes Q No $0.00 Advanced Planning Fees: A Travel Documentation Fee: ITRA VDOC $45.00 Strong. Motion Fee IBSEISAHCR $0.50 Select an Administrative Item 131dg. Stcls Commission Fee: IBCBSC $1.00 SUBTOTALS: $178.50 $0.00 TOTAL FEE: 1 $178.50 Revised: 07/01/2012 CUPERTINO GENERAL PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 • building0guoenno.org ❑PLU B3ING❑ICY 4,�CAL ELECTRICAL ❑NUSCELLANEOUS o►1► mtp MISC PROSECT ADDRESS 2 3 — 30 ' VV J L_1:.. Lo' CQ i.� a I OWNER NAME _ o U U L- PrYL At �A PHJM ONE _ � 2a E MAE C9w(9lt . STREET ADDRESS CRY, STATE ZIP FAX CONTACT NAME PHONE E-MAIL STREEr ADDR-q CITY,STATE ZIP FAX ❑ OwNER ❑ 0w -BUDDER ❑ OWNER AI r yK'OMAACiVR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEV PM ❑ TNANT CONTRACTONAME CM ' l ` LICENSE NUMBER LICENSE TYPE 3 s BLS. LICq COMPANY NAME /, ,I u ( /011 ,�MV C�o� E-MAIL� i VC ICDw�MuCnw4 l'Jj-( 1 1v FAX Y STREET ADDRESS 5-�` CRY, STATE ZIP CID :3q l si', LGS ALMS '7go2 PHONE I Sd IX6-`t313 ARC?ITECT/FNG^1EuZ NAME I• i LICEtSENUISER •U I BUS. LIC4 COMPANY NAME ' E-MAIL I FAX STREET ADDRESS I CITY, STATE ZIP I PHONE USE OF ❑ SFD a DUPLEX ❑ MULTI -FAMILY PRDTECT IN WI DL1ND ❑ YES PROTECT IN ❑YES IS THS BLDG AN ❑ YES BURDN'G: ❑COM cIAI. URBAN INTERFACE AREA ❑ NO FLOODZONE ❑ NO ECCER HOME] ❑ NO DESCRIPTION OF WORK TOTAL VALUATION: S(/9 RECEIVED BY: By my signature below, I cmtiPy to each of the following: I am the property ow or authoriud ages[ W act on the prop<rry pwvcr's behalf. I have read this application and tale information I have provided is ccrrecL I have read the D 'tion of Work and verify it is accurate. I ag er m comply with all applicable local ordinances and state laws relating m building consnved ria rep tadves of Cuperine to enmr the above-idend cd pmp ,,-1 for inspection pu:�,=. Signature ofAppiicwVAgrno Daze: / SUPPLE I AL INFORMATION REQUIRED OFFICE USE ONLY y q OLS VER-THE-COU,uTER t ❑ EXPRESS u U ❑ STANDARD Z J ❑ LARGE ❑ MAJOR df6Pbftre4pp_2011.doc revised 06/21/11