13030155 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 22175 VIA CAMINO CT CONTRACTOR:THD AT-HOME PERMIT NO:13030155
SERVICES,INC.
OWNER'S NAME: ASHOK AGARWAL 2690 CUMBERLAND PKWY STE 300 DATE ISSUED:03/28/2013
OWNER'S PHONE: 4089919910 ATLANTA,GA 30339-3913 PHONE NO:(510)731-1004
XLICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL❑ COMMERCIAL
License Class C f Lic.# 6 O 2 INSTALL(3)RETROFIT WINDOWS,LIKE FOR LIKE,NO
11,, c SIZE CHANGE(TEMPERED TO MEET EGRESS WHERE
Contractor THD A, k;00f"Sc-Z . Date L� 13 APPLICABLE).
I hereby affirm that I am licensed under the provisions of Chapter 9
(commencing with Section 7000)of Division 3 of the Business&Professions
Code and that my license is in full force and effect.
I 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 the Labor Code,for the
performance of the work for which this permit is issued. Sq.Ft Floor Area: Valuation:$4490
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:32646012.00 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.I agree to comply with all city and county ordinances and state laws relating WITHIN 180 DA 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 T CA INSPECTION.
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the3
granting of this permit. Additionally,the applicant understands and will comply Issue y: Date:
3(zg with all non-point source regulations per the Cupertino Mun' ' ode,Section
9.18.
J�� RE-ROOFS:
Signature Date "75 All 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.
❑ OWN -B ER DECLARATION
Signature of Applicant: Date:
I hereby affirm tha am exempt from the Contractor's License Law for one of
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&Professions Code)
I,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. I 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&Safety Code,Section 25532(a)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 Quality Management District I
performance of the work for which this 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&Safety Code,Sections 25505,25533,and25534.
Section 3700 of the Labor Code,for the performance of the work for which this 3 2
permit is issued. Owner or authorized agent: Date:
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
Compensation laws of California. If,after 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 deemed revoked. work's for which this permit is issued(Sec.3097,Civ C.)
Lender's Name
APPLICANT CERTIFICATION Lender's Address
I certify that I have read this application and state that the above information is
correct.I 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 ARCHITECT'S DECLARATION
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue 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
CONSTRUCTION PERMIT APPLICATION �p
10 COMMUNITY DEVELOPMENT DEPARTMENT-BUILDING DIVISION O
10300 TORRE AVENUE-CUPERTINO,CA 95014-3255
CUPERTINO (408)777-3228-FAX(408)777-3333-build ino(d)cuoertino.orp \
❑NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION/TI ❑ REVISION/DEFERRED ORIGINAL PERMIT#
PROJECT ADDRESS �I I / ' /� (� APN# � / _ - 0 /
O / 2-
OWNER NAME ^� O / V� f PHONE /0 E-MAIL
STREET ADDRESS CITY,STATEZIP FAX
Z2 ► 6 1 o c—T- �� :,� 7WQ I GA . `�5 B/4
CONTACT NAME JEFF RAINEY PHONE 510-427-4260 E-MAILJEFFREY.RAINEY@ATT.NET
STREET ADDRESS 1069 EDGEMERE LANE CITY,STATE,ZIP HAYWARD, CA 94545 FAX 510-783-1041
11 OWNER ❑ OWNER-BUILDER 11 OWNER AGENT ❑ CONTRACTOR 43 CONTRACTOR AGENT ❑i,tLARCHITECT
11 ENGINEER El DEVELOPER 11 TENANT
CONTRACTOR NAME LICENSE NUMBER 836021 fi E 4 3,C17 BUS.LIC#
COMPANYNAME THD AT HOME SERVICES
E-MAIL FAx 510-783-1041
STREET ADDRESS 2 4 5 6 VERNA COURT CITY,STATE,ZIP SAN LEANDRO,CA 94577 PHONE 510-7 8 5-6 3 4 0
ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC#
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
DESCRIPTION OF WORK 1 1 5_TA_Z,1_.
EXISTING USE PROPOSED USE CONSTR.TYPE I #STORIES
USE TYPE OCC. SQ.FT. VALUATION($)
EXISTG NEW FLOOR DEMO TOTAL
AREA AREA AREA NETAREA
BATHROOM KITCHEN OTHER
REMODEL AREA REMODELAREA REMODELAREA
PORCH AREA I DECK AREA TOTAL DECK/PORCH AREA I GARAGE AREA: DETACH
❑ATTACH
#DWELLING UNITS: IS A SECOND UNIT ❑YES SECOND STORY ❑YES
BEING ADDED? ❑NO ADDITION? []NO
PRE-APPLICATION ❑YES IF YES,PROVIDE COPY OF IS THE BLDGAN ❑YES `* TOTAL VALUATION:
PLANNINGAPPL# []NO NO PLANNING APPROVALLETM EICHLERHOME? E3 NO
By my signature below,I certify to each ofthe following: I am the property owner or orize ent toactthe rty er's behalf. have read this
application and the information I have provided is correct. I have read the Description of Wo and verify it" a e. I ee to comply with all applicable local
ordinances and state laws relating to building construction. I authorize representatives ofCupertiva. e abo entified property for inspection purposes.
Signature of Applicant/Agent: Date: 51/2A
SUPPLEMENTAL INFORMAT D
)]ZE .C„IC.Y;PE.. ROUTING SLIP
_New SFD or Multifamily dwell' - p y for demolition permit forvER=THE-COUNTER ❑ BUILDING PLAN REVIEW
existing building(s). Demolition permit is required prior to issuance of building
permit for new building. ❑ EXRItES5 ❑ PLANNING PLAN REvIEw
_Commercial Bldgs: Provide a completed Hazardous Materials Disclosure STANDARD ❑ PUBLIC WORKS
form if any Hazardous Materials are being used as part of this project. El LARGE, ❑ FIRE DEPT
_Copy of Planning Approval Letter or Meeting with Planning prior to ❑!; MAJOR El SANITARY SEWER DISTRICT
submittal of Building Permit application.
❑ ENxM_QNMENTAL HEALTH
B1dgApp2011.doc revised 06121111
CITY OF CUPERTINO
FEE ESTIMATOR-BUILDING DIVISION
ADDRESS: 22175 VIA CAMINO CT DATE: 03/28/2013 REVIEWED BY: MELISSA
APN: 326 46 012 BP#: "VALUATION: 1$4,490
*PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration/ Repair
PRIMARY SFD or Duplex PENTAMATION 1GENRES
USE: PERMIT TYPE:
WORK INSTALL 3 RETROFIT WINDOWS LIKE FOR LIKE NO SIZE CHANGE TEMPERED TO MEET
SCOPE EGRESS WHERE APPLICABLE).
rgx
gg
!Meeh. Plan Check Phwtb. Plan Check F_.Iec:..Plan Check
/1ec1,.Permit Fee: Plumb.Permit Feer. Elec. Permit ree:
Other Mech.Insp. Other Plumb Insp. Li Other Elee.Insp.
Allech. Insp.Fee: Plumb. Insp.Fee: Elec,Insp.Fee:
NOTE:This estimate does not include fees due to other Departments(La Planning,Public Works,Fire,Sanitary Sewer District,School
District,eta). These ees are based on the prelimina information available and are only an estimate- Contact the Dept for addn'l info.
FEE ITEMS 6Eee Resolution 11-053 E . 7111121 FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 = # Window/Sliding Glass Door
Suppl. PC Fee: Reg. 0 OT0.0 hrs $0.00 $400.00 1 WINREP Replacement
PME Plan Check: $0.00
Permit Fee: $0.00
Suppl. Insp. Feer Reg. "®OT0,0 hrs $0.00
PME Unit Fee:. $0.00
PME Permit Fee: $0.00
Constrztction Tax:
Administrative Fee:
Work Without Permit? ® Yes 0 No $0.00
Advanced Planning Fee. $0.00 Select a Non-Residential 0
Travel Documentation Fees. Building or Structure. .®
Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $1.00
$1.50 $400.000 FLE $401.50
_S,
Revised: 01/01/2013
Building Department
City Of Cupertino
10300 Torre Avenue
Cupertino,CA 95014-3255
C U P E RT I N O Telephone: 408-777-3228
Fax:408-777-3333
CONTRACTOR/SUBCONTRACTOR LIST
JOB ADDRESS: A GA ti i GST PERMIT# t7"
OWNER'S NAME: A,5tfoK6tj L PHONE# O
GENERAL CONTRACTOR: A-7 HoOr dlec BUSINESS LICENSE#
ADDRESS: 24-% L-'"A 6J. CITY/ZIPCODE: 17 ,4157
*Our municipal code requires all businesses working in the city to have a;City of Cupertino business license.
NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE
GENERAL CONTRACTOR AND ALL SUBCONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO
BUSINESS LICENSE.
I am not using any subcontractors:
Z;e!the
Date
Please check applicable subcontractors and following information:
SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE#
Cabinets &Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring/Carpeting
Linoleum/Wood
Glass/Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Painting/Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/Contractor Signature Date
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