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11090014 CITY OF CUPFRTINO BUILDING PERMIT BUILDING ADDRESS: 18970 NEWSOM AVE CONTRACTOR:SAMPAT SHAILESH& PERMIT NO: 11090014 BHAVNA TRUSTEE OWNER'S NAME: SAMPAT SHAILESH&BHAVNA TRUSTEE 7181 STOESSER CT DATE ISSUED:09/02/2011 NER'S PHONE: 4084251741 SAN JOSE,CA 95124 PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL❑ COMMERCIALE] License Class Lie.# INSTALL TEMP POWER POLE Contractor Date 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:$1000 I 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:37535014.00 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 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 ST CALLED INSPECTI indemnify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City in consequence of the 7• granting of this permit. Additionally,the applicant understands and will comply Issued by: Date: with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. RE-ROOFS: Signature Date 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. OWNER-BUILDER DECLARATION Signature of Applicant: Date: I 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 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,and 25534. Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agent: �.-��"�-tet � Date: 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 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 ^,lemnify and keep harmless the City of Cupertino against liabilities,judgments, and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records. ating 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 t 1 CITY OF CUPERTINO 6 ITEMS OF 6 PERMIT RECEIPT OPERATOR: SylviaM COPY # 1 Sec : Twp: Rng: Sub: Blk: Lot: APN . . . . . . . . : 37535014 . 00 DATE ISSUED. . . . . . . : 09/02/2011 RECEIPT # . . . . . . . . . : BS000014661 REFERENCE ID # . . - : 11090014 SITE ADDRESS . . . . . : 18970 NEWSOM AVE SUBDIVISION . . . . . . CITY . . . . . . . . . . . . . . CUPERTINO IMPACT AREA . . . . . . OWNER . . . . . . . . . . . . : SAMPAT SHAILESH & BHAVNA TRUST ADDRESS . . . . . . . . . . : 7181 STOESSER CT CITY/STATE/ZIP . . . : SAN JOSE, CA 95124 RECEIVED FROM . . . . : BHAVNA SAMPAT CONTRACTOR . . . . . . . : LIC # *OWNER* COMPANY . . . . . . . . . . : SAMPAT SHAILESH & BHAVNA TRUST ADDRESS . 7181 STOESSER CT CITY/STATE/ZIP . . . : SAN JOSE, CA 95124 TELEPHONE . . . . . . . . : FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- ---------- -ADMIN HOURS 1 . 00 41. 00 0 . 00 41 . 00 0 . 00 1BCBSC VALUATION 1, 000 . 00 1. 00 0 . 00 1 . 00 0 . 00 1BSEISMICR VALUATION 1, 000 . 00 0 .50 0 . 00 0 .50 0 . 00 1EPERMITFE FLAT RATE 1 . 00 44 . 00 0 . 00 44 . 00 0 . 00 1ERT<200 UNITS 1 . 00 44 . 00 0 . 00 44 . 00 0 . 00 1TRAVDOC FLAT RATE 1 . 00 44 . 00 0 . 00 44 . 00 0 . 00 ---------- ---------- ---------- ---------- TOTAL PERMIT 174 .50 0 . 00 174 .50 0 . 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CREDIT CARD 174 . 50 MC --------------- TOTAL RECEIPT 174 . 50 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 402 TEMPORARY POWER CITY OF CUPERTINO FEE ESTIMATOR- BUILDING DIVISION I V ADDRESS: 18970 newsom ave. DATE: 09/02/2011 REVIEWED BY: bob s. APN: BP#: "VALUATION: $1,000 y°PERMIT TYPE: Electrical Permit PLAN CHECK TYPE: Alteration /Addition / Repair PRIMARY SFD or DuplexT PENTAMATION 1 REAP14 USE: PERMIT TYPE: WORK install temp power pole SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Temporary Power 1ERT<200 100 Amps $44 TOTALS: $44.00 Elec.Plan Check 0.0 1 hrs $0.00 FElec.Permit Fee: ]EPERMIT LjOther Elec.Insp. 0.0 hrs $44.00 NOTE: Thesefees are based on the prelintinary information available and are only an estimate. Contact the De t or addh 7 info. FEE ITEMS (F'ee Resolution 11-053 f -"11) FEE QTY/FEE MISC ITEMS PME Plan Check: $0.00 PME Unit Fee: $44.00 PME Permit Fee: $44.00 Work Without Permit? 0 Yes No $0.00 Travel Documentation Fee: ITRA VDOC $44.00 Strong Motion Fee: 1BSEISMICR $0.50 0.5 hrs Admin./Clerical Fee Bldg Stds Commission Fee: ]BCBSC $1.00 $41.00 ]ADMIN SUBTOTALS: $133.50 $41.00 TOTAL FEE: $174.50 Revised: 07/04/2011 GENERAL PERMIT APPLICATION MEP COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION Lis 10300 TORRE AVENUE •CUPERTINO, CA 95014-3255 CUPERT{NO (408)777-3228 • FAX(408)777-3333• buildlng(CDcupertin0.org misc ❑PLUMBING ❑MECHANIC,4? ELECTRICAL ❑MISCELLANE04 PROJECT ADDRESS , ^ I, l �� AFN# OWNER NAME ` - o��e �� PHONELt 0�— 4,� l_til� E-MAIL J�� @ '"\ �L� �VIA STREET ADDRESS f L^'� , �+ S e� CITY, STATE,ZIP j J, FAX C CONTACT NAME l 4 00 4 ZS—I \4 E-MAIL S 1 Cr L• IA L STREET ADDRESS 1 ` �� L� CITY,STATE, ZIP C ^ � FAX4 D. / S, g fi�OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME LICENSE NUMBER LICENSE TYPE BUS.LIC# COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE ARCHITECTIENGINEER NAME LICENSE NUMBER BUS.L1C# COMPANY NAME' E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE ISE OF SFD or DUPLEX ❑ MULTI-FAMILYPROJECT IN WILDLAND ❑ YES PROJECT IN ❑YES IS THE BLDG AN ❑YES BUILDING COMMERCIAL 7 URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑NO EICHLER HOME? ❑NO DESCRIPTION OF WORK �JY TOTAL VALUATION: C�Fa C� 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 progerty owner's behalf. I have read this application and the information I have provided is correct.,,have read the Description of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating to building construction:I authorize representatives of Cupertino to enter the above-identified property for inspection pudposes. Signature of Applicant/Agent: il * — Date: SUPPLEMENTAL INFO TION REQUIRED OFFICE USE o VER-THE-COUNTER c ❑ EXPRESS U w ❑ STANDARD u ❑ LARGE ❑ MAJOR ML'PMiscApp_2011.doc revised 06/21/11