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11080214 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 21150 GRENOLA DR CONTRACTOR:NORDIN BUILDERS,INC PERMIT NO: 11080214 OWNER'S NAME: SUBIR SENGUPTA&HERRERA ELENA 1759 VALHALLA CT DATE ISSUED:08/30/2011 ONVNER'S PHONE: 4082520504 SAN JOSE,CA 95132 PHONE NO:(650)396-7721 LICENSED CONTRACTOR'S DECLARATION /,Q BUILDING PERMIT INFO: BLDG ELECT PLUMB /, License Class Lic.# '1�f -1 qdq MECH RESIDENTIAL COMMERCIAL Contractor Date 8" I hereby affir that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:INSTALL TEMPORARY POWER POLE (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:$200 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 permit is issued. APN Number:32628059.00 Occupancy Type: APPLICANT CERTIFICATION 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 PERMIT EXPIRES IF WORK IS NOT STARTED to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We)agree to save WITHIN 180 DAYS OF PERMIT ISSUANCE OR indemnify and keep harmless the City of Cupertino against liabilities,judgments, 180 DAYS FROM LAST CALLED INSPECTION. costs,and expenses which may accrue against said City in consequence of the granting of this permit. Additionally,the applicant understands and will comply with all non-point sou egu ons per the Cupertino Municipal Code,Section Issued by:-�'2—"'�""�" ��T Date: 9.18. "k r Signature Date 0- f RE-ROOFS: r OWNER-BUILDER DECLARATION 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 I hereby affirm that I am exempt from the Contractor's License Law for one of inspection. the following two reasons: 1,as owner of the property,or my employees with wages as their sole compensation, Signature of Applicant: Date: will do the work,and the structure is not intended or offered for sale(Sec.7044, Business&Professions Code) 1,as owner of the property,am exclusively contracting with licensed contractors to ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER construct the project(Sec.7044,Business&Professions Code). I hereby affirm under penalty of perjury one of the following three HAZARDOUS MATERIALS DISCLOSURE declarations: I have read the hazardous materials requirements under Chapter 6.95 of the I have and will maintain a Certificate of Consent to self-insure for Worker's California Health&Safety Code,Sections 25505,25533,and 25534. I 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 Health& performance of the work for which this permit is issued. Safety Code,Section 25532(a)should I store or handle hazardous 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 contaminants as defined by the Bay Area Air Quality Management District I will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the permit is issued. Health&Safe , ections 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 Owih r a ed ag t:-r Compensation laws of California. If,after making this certificate of exemption,I Date: v �� 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 affirm that there is a construction lending agency for the performance of work's APPLICANT CERTIFICATION for which this permit is issued(Sec.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 with all city and county ordinances and state laws relating to building construction,and 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, cc and expenses which may accrue against said City in consequence of the ARCHITECT'S DECLARATION :g of this permit.Additionally,the applicant understands and will comply I understand my plans shall be used as public records. w;_all non-point source regulations per the Cupertino Municipal Code,Section 9.18. Licensed Professional Signature Date CITY OF CUPERTINO 6 ITEMS OF 6 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN . . . . . . . . : 32628059. 00 DATE ISSUED. . . . . . . : 08/30/2011 RECEIPT #. . . . . . . . . : BS000014607 REFERENCE ID # . . . : 11080214 SITE ADDRESS . . . . . : 21150 GRENOLA DR SUBDIVISION . . . . . . CITY . . . . . . . . . . . . . . CUPERTINO IMPACT AREA . . . . . . OWNER SUBIR SENGUPTA& HERRERA ELENA ADDRESS . . . . . . . . . . : 21150 GRENOLA DR CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM . . . . : JAN NORDIN CONTRACTOR . . . . . . . : DANIEL NORDIN, CEO LIC # 32813 COMPANY . . . . . . . . . . : NORDIN BUILDERS, INC ADDRESS . . . . . . . . . . : 1759 VALHALLA CT CITY/STATE/ZIP . . . : SAN JOSE, CA 95132 TELEPHONE . . . . . . . . : (650) 396-7721 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 200 . 00 1. 00 0. 00 1. 00 0. 00 1BSEISMICR VALUATION 200 .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 VISA --------------- TOTAL RECEIPT 174 .50 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 402 TEMPORARY POWER GENERAL PERMIT APPLICATION MEP COMMUNITY DEVELOPMENT DEPARTMENT- BUILDING DIVISION 10300 TORRE AVENUE-CUPERTINO, CA 95014-3255 CUPERT[NO (408)777-3228- FAX(408)777-3333- building(c)cuoertino.org misc ❑PLUMBING ❑MECHANICAL ELECTRICAL ❑NOCELLANEOUS PROJECT ADDRESS W V£ APN# t_> OWNER NAME V�C�"�Vr26VZ PxoNE ee✓ - rq a)rx);c'o� STREET ADDRESS21 i 5ra ✓�hL1�� CITY, STATE,ZIP FAX I D4-r✓e Gu"erInwo 61q C/�l�I IS' CONTACT NAME J J_0 HAI` A�Q/�iCJ I,` PHONE /�� a� I216 E jbyl rc{ IAUI STREET ADDRESS CITY,STATE, ZIP T i E Cr4 q S 2 FAX 6 JO (o V/ 17&& ❑OWNER ❑ OWNER-BUILDEP ❑ OWNER AGENT CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME, / r /I U/ JQ I /NG LICENSE NUM`BM LICENSE E BUS.LIC# COMPANY NAME r] ��K / /V E-MAIL U l? Y1dlei y�J/(U QYS, CLQ u'( FAx 4 IIID lO STREET ADDRESS j� •l� r/ , /Q /� CIT�ST ,Z �� ,�13 2 PHONE ARCHTI ECT GIIdEER NAME �A LICENSE NUMBER BUS.LIC# _ _ N SSa C �( COMPANY NAME' E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE ISE OF SPD or DUPLEX ❑ MULTI-FAMILY PROJECT IN WIIALAND ❑ YES PROJECT IN ❑YES IS THE BLDG AN ❑YES BUILDING: ❑COMMERCIAL URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑NO tEICHLER HOME? ❑NO DESCRIPTION OF WORK We-r TOTAL VALUATION: r RC1 RECEIVED BY: C6 By my signature below,I certify to each of wi I am the property owner or authorized agent to act on the property owner's behalf. I have read this application and the information I hav rovi i rrect.j have read the Description of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating t b ]ding ctiony I authorize representatives of Cupertino to enter the above-identified property for inspection pu(poses. Signature of Applicant/Agent: Date: SUPP MENTAL INFORMATION REQUIRED OFFIC�USE ONLY w OVER-THE-COUNTER G ❑ EXPRESS U W ❑ STANDARD U ❑ LARGE ❑ MAJOR AEPMiscApp_2011.doc revised 06/21111 CITY OF CUPERTINO FEE ESTIMATOR- BUILDING DIVISION F91 ADDRESS: 21150 grenola dr. DATE: 08/30/2011 REVIEWED BY: bobs. APN: BP#: 'VALUATION: $200 *PERMIT TYPE: Electrical Permit PLAN CHECK TYPE: Alteration /Addition / Repair PRIMARY SFD or Duplex PENTAMATION 1 REAP14 USE: p 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 Elec.Permit Fee: 1EPERMIT LjOther Elec.Insp. OA hrs $44.00 NOTE: Theseees are based on the preliminary information available and are only an estimate. Contact the De t or addh 7 info. FEE ITEMS (hee Resolution I1-053 Ef..' 71,"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 E) No $0.00 Travel Documentation Fee: ITRA VDOC $44.00 Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $1.00 SUBTOTALS: $133.501 $0.00 TOTAL FEE: 1 $133.50 Revised: 07/04/2011 Building Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014-3255 Telephone: 408-777-3228 C U P E RT I N O Fax: 408-777-3333 CONTRACTOR/ SUBCONTRACTOR LIST JOB ADDRESS: V5o V'@wo a Zee- PERMIT# f(C(o0C<:)4- OWNER'S NAME: C/enq Wcrrc-rq PHONE # 6 -/Z0 GENERAL CONTRACTOR: gord l h hu%l V-S /n c�-. BUSINESS LICENSE# Y 17 "o ADDRESS: /I§y i4LN44 p G� 4S1�Z CITY/ZIPCODE: day(, CA qs 1371 *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: - Signature Date Please check applicable subcontractors and complete the 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