12080019 CiTY OF CUPERTINO BUILDING PERMIT
BUILDINGADURESS: 10569SANLEANDRO CONTRACTOR:PAUL KALRA PERMITNO: 12080019
OWNER'S NAME: PAUL KALRA P 0 RON 23826 DA'Z'E ISSUED:08!062012
OWNER'S PBO,NE: 9256762921 PLEASANTIIILL.CA 94523 PIIONENO:
❑ LICENSED CONTRACT'OR'S DIiCLARAIION BUILDING PERMIT INFO: BLDG r ELECT r PLUMB r
License Class Lie.is
A1EC11 r RESIDENTIAL r COMMERCIAL
Contractor Date
hereby affirm that I am licensed under the provisions of Chapter 9 •1013 DESCRIPTION:TEMPORARY POWER POLE
(commencing with Section 7000)of Division 3 of the Business S 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 which this pemtit is issued. Sq. Ft Floor Area: Valuation:$300
1 have and will maintain Worker's Compensation Insurance,as provided Ibr by
Section 3700 of the Labor Code,for the performance of the work for which this
pemtit is issued APS Number:35705079.00 Occupancy Type:
.\I'PLIC.\N"1'CIiR'I'I PIC.\'I'ION
I certify that I have read this application and state that the above information is
correct.l agree to comply with all city and county ordinances mid state laws relating PERMIT EXPIRES IF WORK ISNOT STARTED
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property fir inspection purposes. (We)agree to save WITHIN 180 DAYS OF PERMIT ISSUANCE OR
indemnify and keep harmless the City of Cupertino against liabilitiesjudgments, 180 DAYS FROM L ALLED INSPECTION.
costs,and expenses which may accrue against said City in consequence of the
granting of this pemtit. Additionally,the applicant understaids and will comply j L L
with all non-point source regulatinis per the Cupertino Municipal Code,Section Issued by: —Date:
9.18.
Signature Date
Rb:ROOFS:
O\YNER-BUILDER DECLARATION All roofs shall be inspected prior to any roofing material beiig installed If a roof is
installed without first obtaining an inspection,I agree to remove all new materials for
1 hereby affirm thin I am exempt front the Contractor's License Law frolic of inspection.
the following Iwo reasons:
I,as owner of the property,or my employees with wages as their sole coniM1nsation. Signature of ApplivanC Date:
will do the work,mid die structure is not intended or offered for sale(Sec.7044,
Business S Professions Code)
1,as owner of the property,am exclusively contracting with licensed contractors to ALL ROOF COVERINGS•1'O BE CLASS"A"Olt Bf`I-f ER
construct the project(Sec.7044,Business K Prolissions Code).
hereby affirm under penalty of perjury one of the following three IIA%ARDOUS MATERIAL S DISCLOSURE
declarations: I have read the hazardous materials requirements under Chapter 6.95 of the
I.have and will maintain a Cenificme of Consent m self-insure for Worker's California Ihealth S Safet Code Sections 2.5505,25533,and 25534. 1 will maintain
Compensation,as provided for by Section 3700 of the Labor Code,for the compliance with the Cupertino Municipal Code.Chapter 9.12 and the I Icalth S
performance of the%cork for which this permit is issued. Safety Code.Section 25532(a)should I store or handle hazyrdous material.
I have and will maintain Worker's Compensation Insurance,as provided for by Additionally,should I use equipment or devices which emit hazardous air
Section 3700 of the labor Code,for the performance of the work for which this comm�ifnams as defined by the Bay Area Air Quulily Managenment District I will
permit is issued maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
F Ilenith&Safety Code.Sections 25505,25533,and 25534.
1 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 {honer or audo zed ag uI � / -
ConipmisationlawsofCnlifornia. If,alien making this certificate of escniption,lDate: _D 7C t�
become subject to the Worker's Compensation provisions of the Labor Code,I must
forthwith comply with such provisions or this permit shall be deemed revoked CONSTRUCTION LENDING AGENCY
I hereby a0inn than there is s construction lending agency for the performance of work's
APPLICANT CERTI FICAIION for which this permit is issued(See.3097,Civ C.)
I certify that I have read this application and state that the above information is Lender's Name
correct.I agree to comply wish all city and count•ordinances and slate laws relating
to building construction,mid hereby authorize representatives of this city to enter Lender's Address
upon the above mentioned property for inspection purposes.(We)agree to save
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the ARCDITECI"S DECLARATION
granting of this permit.Additionally,the applicmt understands and will comply I understand my plans shall be used as public records.
with all non-pont urce regulatiams per the Cupertino Municipal Code,Section
9.18. 1++ Licensed Professional
Signature l� Dale ��Z
CITY OF CUPERTINO
FEE ESTIMATOR — BUILDING DIVISION
ADDRESS: 10569 san leandro DATE: 08/06/2012 REVIEWED BY: larrys
:12 APN: BP#: 'VALUATION: $300
*PERMIT TYPE: Electrical Permit PLAN CIIECK TYPE: Alteration /Addition / Repair
PRIMARYPENTAI\WTION
USE: SFD or Duplex PERMITTYPE: 1REAP1
WORK temporary ower pole
SCOPE
APPLIANCE/EQUIP TYPE FEE II) QTl' UNITS BP FEES
Temporary Power 1ERT<200 100 Amps $45
TOTA LS: $45.00
Alech.Plan Check Phuub. Plan Check Elec. Plan Check 0.0 1 hrs $0.00
Mech.Permit Fee: Plumb. Permit Fre: Elce. Permit Fee: 1EPERMIT
Other Afech. Insp. Other Plumb Insp. Other Elea Insp. 0.0 hrs $45.00
Alech. Imp. Fee: Plumb. hmp.Fee. Elcc.Insp. Fee:
A'OTE: This evtinmte Anes nor inchule feev due to other Departments(i.e. Planning, Public Works, Fire.Sanitury Server District,School
District. etc.). These eev are based on the hreliminarl•in ortnulion available and are only an estimate. Contact the De t or athin7 info.
FEE ITEMS (Fce Resohhtion 11-053 Ejj 711/1/) FEE QTY/FEE MISC ITEMS
Plan Check Fee:
Sup/I/. PC Fee
PME Plan Check: $0.00
Permit Fee:
SuppL Luep Fee
PME Unit Fee: $45.00
PME Permit Fee: $45.00
Construction Tac:
Administrative Fee: 1D,tnv $42.00
Work Without Permit? O Yes Q No $0.00
I dvanced Planning Fees:
Travel Documentation Fee: ITRAVDOC $45.00
i
Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $1.00
SUBTOTALS: $178.50 $0.001 TOTAL FEE: $178.50
Revised: 07/01/2012
' OWNER-BUILDER DISCLOSURE FORM
COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION
10300 TORRE AVENUE •CUPERTINO,CA 95014-3255
CUPERTINO (408)777-3228•FAX(408)777-3333• buildina6cuoertino.oro
Dear Property Owner(s):
An application for a building permit has been submitted in your name listing yourself as the builder of the property
improvements specified at:
SITE ADDRESS rD 54 r7 SeLv. 1 _ I APN '3 D BP#
OWNER NAME (... y' . OWNER ADDRESS 2
,, ` � P t1. �do 3 9'4
DESCRIPTION OF WORK: T c c
We are providing you with an Owner-Builder Acknowledgment and Information Verification Form to make you aware of
your responsibilities and possible risk you may incur by having this permit issued in your name as the Owner-Builder. We
will not issue a building permit until you have read, initialed your understanding of each provision, signed, and
returned this form to us at our official address indicated. An agent of the owner cannot execute this notice unless
you, the property owner, obtain the prior approval of the permitting authority.
OWNER'S ACKNOWLEDGMENT AND VERIFICATION OF INFORMATION
(DIRECTIONS:Please read and initial each statement below to signify you understand or verify this information.)
1. 1 understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner-
Builder" building permit that erroneously implies that the property owner is providing his or her own labor and material
personally. I, as an Owner-Builder, may be held liable and subject to serious financial risk for any injuries sustained by
an unlicensed person and his or her employees while working on my property. My homeowner's insurance may not
provide coverage for those injuries. I am willfully acting as an Owner-Builder and am aware of the limits of my
insurance coverage for injuries to workers on my property.
P``2. 1 understand building permits are not required to be signed by property owners unless they are responsible for
the construction and are not hiring a licensed Contractor to assume this responsibility.
t2t=3. 1 understand as an "Owner-Builder" I am the responsible party of record on the permit. I understand that I may
protect myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her
name instead of my own.
Pr-4. I understand Contractors are required by law to be licensed and bonded in California and to list their license
numbers on permits and contracts.
P r-5. 1 understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the
total value of my construction is at least five hundred dollars ($500), including labor and materials, I may be
considered an "employer" under state and federal law.
12r--6. I understand if I am considered an "employer" under state and federal law, I must register with the state and
federal government,withhold payroll taxes, provide workers' compensation disability insurance, and contribute to
unemployment compensation for each "employee." I also understand my failure to abide by these laws may subject
me to serious financial risk.
X-7. I understand under California Contractors' State License Law, an Owner-Builder who builds single-family
residential structures cannot legally build them with the intent to offer them for sale, unless all work is performed by
licensed subcontractors and the number of structures does not exceed four within any calendar year, or all of the work
its performed under contract with a licensed general building Contractor.
1 r— 8. I understand as an Owner-Builder if I sell the property for which this permit is issued, I may be held liable for
any financial or personal injuries sustained by any subsequent owner(s)that result from any latent construction
defects in the workmanship or materials.
avnerBuilderForm 1010.doc revised 04/14//0
OwnerBuittlerFornt 1010.doc revised 04/14/10
GENERAL PERMIT APPLICATION E
CONIMUNI T`(DEVELOPMENT DEPARTMENT• BUILDING DIVISION
10300 TORRE AVENUE •CUPERTINO, CA 95014-3255 w w I
CUPERTINO (408)7 t-3228 • FAX(408)777-3333 • bulil�dinc(acucerdno.orc �I ��I
SC
❑PLUMBING�y,, ❑\\NIEC:A.MiCALZZLECiRCAL-y LJ�IISC�L±NEOUS
FAClcCi ADDREsS�O.J(7q STNV �2pCLv�C✓s� ,(.4��cy-h�V..a �R 3-(9�•I_
OWNER NAME ROWL KA-L-(--R
HONE02S 6�L-ZYZ , E�¢CitI G�I QT (� ✓yfl�IM 41�• LJ+�
STREET AODREss 11Q p, (!10 x I�2���Zf CITY STAT-,ZIP �le 3 C A 0 57� FAX
CONTACT NAME 1 I PHONE I E-MM.
STREETADORESS CITY,STAT$ ZIP FAX
0 O0.vFR ❑ OWNER-BUIlDR ❑ 0W, ADEM 13 CONTRACTOR ❑CONTRACMRA= ❑ AROU ECT ❑E4(3 IE ❑ DEVEOPM ❑ TENANT
CONiRACTORNAME LICIMENUMBEt LIC'E'NSE TYPE I BUS _ICN
CO1(FA.NY NAME+/p (� /1 L. � MAIL I FAX
S ADDRESS !.� l I CPY.STATE.ZIP 11-91517
Z
ARC411"EMENGLNEM NAME LICENSE XUlIBR BUS.L'C p
COIWANY NAME' - I E-MAB. I FAX
STREET ADDRESS CITY.STATE.ZIP PHONE
USE OF El
MMERCIAL SPO a OUPLEt ❑ MULTI-F.Nay PROPER IN WB LVN O n3 PROJECT IN ❑YS I IS TIMBLDGAN CI YES
BUILZING: COURBAN M'1-cAFACB ARE> NO FLOOD ZONE ❑ ND pOR.ER HOMF! ❑ NO
DESCRIPTION OF WORX rr
xTem d' 1=IetC1iG P° Iz
A( TOTAL VALUATION: 3 T� C) I RECEIVED BY:
/\ By my signature below,I cerdty a each of the following; I am the property owner or authorized agem m act an the prupcy wner's behalf. I have road this
application and the iiormation I have provided t Corr sCL I have read the Description of Work and verify is is accurate. I agu x comply wilt all applicable local
ordinances and state laws mlatirg to building cdotyy 1 aria repro mdvu of Cupeninc:�enter;.':e abo/vee-id=dHedpropc y:or inspection pu:$oses.
Signature of Applicart/Agem: ��\ ' Date; /T"� 17 1 LC I Z
SUPPLENE N'TAL INFOR-NLATi0N REQUIRED OFFICE USE ONLY
VOVER-THE-COUNTER
❑ EXPRESS
's
O
❑ STANDARD
U
Z ❑ LARGE
❑ NUOR
AEP.Wue4pp_20/1.doc revised 06P1111