12100007 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 11305 TERRA BELLA DR CON FRACI'OR:NT GENERAL PERMIT NO: 12100007
CONSTRUCI'ION CO
O\VNER'S NAMF,: LAHIRI SAYAN AND S ANYAL SHARMISTHA 1351 NORMAN DR DA'Z'E ISSUED: 10/0212012
OWNER'S PHONE: 4084398014 SUNYVALE,CA 94087 PHONE NO:(408)623-2297
❑ LICENSED CON'TRACTOR'S DECLARATION .JOB DESCRIPTION: RESIDENTIAL.U COMMERCIAL
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License Class CO21? Lic.p ( Q ) (REMODEL BATHROOMS MASTER 189 S FT & GUEST 56
��11�9�7
SQFT)AND REPLACE 12 WINDOWS & I SLIDING
Contractor Dale DOOR(ALL
I hereby affirm that l am licensed under the provisions of Chapter LIKE FOR LIKE;NO STRUCTURAL)
(commencing with Section 7000)of Division 3 of the Business&Professions
Code and that mslicense is in full force and effect. -
1 hereby affirm under penalty 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 die Labor Code,for the
performance of the work for which this permit is issued. Sq.Ft Floor Area: Valuation:$20000
I have and will maintain Worker's Compensation Insurance,as provided for by
Section 3700 of the Labor Code,for die performance of the work for which this
,\I'N Number:31625010.00 Occupancy Type:\'p
Permit is issued.
AI'I'LIC.\NI'CERI'IFIG\"PION
I certify that I have read this application mid 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 DAYS FROM LAST CALLED INSPECTION.
indemnify and keep harmless the City of Cupertino against liabilitics,judgninus,
costs,and expenses which may accrue against said City in consequence of the TG/� O ' a'�a
granting of this permit: Additionally,the applicantde
understands and will comply Issued by: ��/� Date:
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18.
�-7� RF-ROOFS:
Signalure Date lD-'2 ;/ 2- A11 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 DECLARA'T'ION
Signature of Applicant: Date:
1 hereby affirm That I am exempt from the Contractor's License Law for one of
the following two reasons: ALL ROOF COVERINGS TO BE.CLASS"A"OR BE'I-I'ER
I,as owner of the property,or my employees with wages as Ihcir sole compensation,
will do the work,and the structure is not intended or offered far 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 health&Safety Code.Sections 25505.25533,and 25534. 1 will
I hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
declarations: health&Safely Code.Section 25532(x)should I 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 QualityManagement District
performance of the work for which this permit is issued. will maintain compliance with the Cu perii o Municipal Code.Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the ilealth&Safet}'Code,Seclions 255 25533,and 25534.
Section 3700 of the Labor Code,for the performance of the work for which this -
Owner or authorized agen . . Date:
permit is issued.
I certify that in the performance of die 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
Compensation Imus of California. If,ager making this certificate of exemption,I CONSTRUCTION LENDING AGENCY
become subject to the Worker's 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 deenhed revoked. work's for which this permit is issued(Sec.3097,Civ C.)
Lender's Name
API'I.JCANI'Cr.RI'IFICA'I'ION Lender's Address
I certify that i have read this application and state that the above information is
correct.1 agree to comply with all city and county ordinances and state Imes 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
indcnaify and keep harmless the City of Cupertino against Iiabililies,judgmcnls, ARCI I ITECT'S DECLARATION
costs,and expenses which may aceme against said City in consequence of the I 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
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BUILDINODM81pN-CUPER� ept ICE COPY
APPROVED
This
job set of plansonstruction. it Is u awfu to nd specifications MUST Ile kmake any , , 1✓
lob site during
changes or alterations on same,or ti devi0fficial.
therefrom,without approval from the Bu ding
The stamping of this plan and specifiCatio aB'El�rvv fr'T DeAT
be held to permit or to be an approval o u ie violauun
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of any provisions of any v OCT 01 2012
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CONSTRUCTION PERMIT APPLICATION I y( L) J uv
COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
CUPERTINO (408) 777-3228• FAX (408) 777-3333• building(cDcupertino.org
❑ NEW CONSTRuc-�rII'1ON O❑ ADDITION ALITHATION I TI ❑ REVISION/DEFERRED ORIGINAL PERMIT 9
I'R01D AI',\N OI
TeerA 'J�UA V'1, -tN, CA 91-D I'!- 2 ��2 5--
11 30S
OWNERNAME PHONE _l E-\IAIL
x:w Ll k LT sfJ Lz 9-9-439- &V LIX" Zo ,tp
a
1,00
STR,E ADDR e��s S � e CITY, STATE,ZIP �. FAX
120 U Cn erwtrv� 7r MtiL ift C , CA )SD35—
CONTACT W\\IE Xznl T PHONE408_439 —Rol E-\IAIL f y� z0bg /YIA1 L•�
STRELT ADDRESS CITY,STATE, ZIP rJ l• FAX
zp Gr 3 S
OWNER El❑ OWNER-RUILDER ❑ OWNER AGENT AY CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT 0 ENGINEER E3 DEVELOPER ❑ TENANT
CONTRACTOR NAME LICENSE NUMBER LICENSETYPE BUS.LIC 0
n OG 9
COMPANYNAME ""'A . FAX N� Genera-� s�vul�lm Co. and \ u �9 Qh nm fam 4D8-?3 o-8"sb
STREET ADDRESS CIp'STATE,ZIP P11NE
1471 as orrY14 Drlvi? 71.L/In v� G 4408 �o8—Gz3-229
ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC✓•
COMPANY NA ME E-\IAIL FAX
STREET ADDRFSS CITY,STATE,ZIP PHONE
DESCRIPTION OF WORK '
Re.rrwdot_ rvYostzv "�bet 199 squrire fekk Lwvl JAest b/At6 sb 5gtA 'e fieot >
fe IM
L&u- t2 OAO-A/3 Curt I 5L1 CoAt .
EXIST ING USE PROPOSED USE CON\TR.TYPE 0S1'ORIES
USE TYPE OCC. SQ.FT. VALUATION(S)
ECISTG NEW FLOOR DEMO TOTAL
AREA ARFA AREA NET AREA
BATHROOM KITCHEN OTHER
REMODLL AREA REMODELARG REMODEL AREA
PORCH A0.G DECK AREA TOTAL DECKMORCH ARG GARAGE AREA: DETACH
[]ATTACH
4 DWELLING UNITS: ISASCCONDU,NT'r ❑YFS SECONDSTOR\' ❑YES
nE1NGADDED? E]NO ADDITTON7 []NO
PRE-APPLICATION ❑YES IFYFS,11ROVIDECOPYOF Is I'ID:DLDG AN ❑YES R17CEIVED B_Y_i. TOTAL VALUATION:
PLANNINGAPPLC E]NO PLANNING APPROVAL LETTER 1:10ILERTIOTIE? 0 N f 20
O0'0
By my signature below,I certify to each of the following: I am the property owner or authorized agent to a on the progeny owner's behalf. I have read this
application and the information I have provided is correct. I have read the Description of\York and verify it is accurate. I agree to comply xvidt all applicable local
ordinances and state laws relating to building construction. I authorize represernatives ofCuperino to enter the above-identified property for inspection purposes.
Signature of ApplicanUAgenl: XH t-� Date: (O f 12—
SUPPLEMENTAL
2SUPPLEMENTAL INFORMATIONREQUIRHD PI-ANCneCK:rrvE _ NourrvcSLIP
_New SPD or Multifamily dwellings: Apply for demolition permit for )01 oYr:R=rue-cousreR Elnuu:urnc rtaN aeYlEw
eNisting building(s). Demolition permit is required prior to issuance of building
permit for new,building. ❑ EXPRESS ❑ rlassin'c PLAN REVIEW
_Commercial Bldgs: Provide a completed Hazardous Materials Disclosure _❑ SIANDARD ❑ 'PUBLIC WORKS
form if any I lazardous Materials arc being used as part of this project.
❑ 1.\ECF. ❑ FIRE DF.i'F
_Copy of Planning Approval Letter or Meeting With Planning prior to _
submittal of Building Permit application. ❑ nuatiN: E) S,\NI'11\Nl'St:\VFN'UIS'1'RICI"
❑ ENVIRON\IEN I'AL UF-ACI'll_
BIc1gApp-2011.doc revised 06121/11
CITY OF CUPERTINO
FEE ESTIMATOR - BUILDING DIVISION
ADDRESS: 11305 terra Bella Dr. DATE: 10/01/2012 REVI1al'ED BY: gs
APN: BP#: WALUATION: $20,000
*PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration / Repair
PRIMARY SFD or Duplex PENTAMATION 1R3SFDREM
USE: I PERMIT TYPE:
WORK Remodel bathrooms master 189 s ft. quest 56 s ft. and replace 12 window and 1 slidind door, All like
SCOPE I for like no structrual.
Alech. Plan Check Plumb.Plan Check Elee. Plan Check
Alech.Permit Fee: Plumb. Permit Fec: rlec•. Permit Fee:
Other Alech.lmrp. - Odrer Plumb Insp. 011ier flee Insp. Li I
Alech.Imp. Fee: Plumb. losp. Fee: Elec. harp.Fee:
NOTE: This estimate does not inchudefees clue to other Departments(i.e. Planning, Public Warks, Fire,Sanitary Sewer District,School
District,etc.). Thesefees are based on the preliminan information available and are only,an estimate. Contact the Delitfor addn'I info.
FEE ITEMS (Fee Resolution 11-053k-ff. 7/1/11) FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 1 s.f. Remodel, Bath (<=300 sl)
Suppl. PC Fee: Q Reg. 0 OT 0.0 hrs $0.00 $600.00 IREA-IRESBAT
PME Plan Check: $0.00 = # Window/Sliding Glass Door
Permit Fee: $0.00 $533.00 1 IWINREP Replacement
Suppl. Insp. Feel@ Reg. 0 OT0.0 11rs $0.00
PME Unit Fee: $0.00
PME Permit Fee: $0.00
Construction Thin:
Administrative Fee: O
Work Without Permit? 0 Yes (j) No $0.00 0
Advanced Planning Pee: $0.00 Select Non-Residential
Travel Documentation Fags: Building or Structure 0
A
Strong Motion Fee: IBSEISMICR $2.00 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $1.00
SUBTOTALS: $3.00 $1,133.00 TOTAL FEE: F$1,136.00
Revised: 07/01/2012