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11080122CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 22140 HIBISCUS DR I CONTTR:SMUTNAKNAK I PERMIT NO: 11080122 I OWNER'S NAME: SUBHA & SURESH TAMMANA 3R'S PHONE: 4087360059 ❑ LICENSED CONTRACTOR'S DECLARATION License Class Lic. # 3 5 0 7p ` / % Contractor Syn L)7� /`�/C OOGyj Date J —�� ( r 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. 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 permit is issued. 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 to building construction, and hereby authorize representatives of this city to enter 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 granting of this permit. Additional b', the a plicant understands and will comply with all non -point sou� ce r gulatx6nfsVe Ia pertino Municipal Code, Section 9.18. Signature Lv DateS, Ci OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: I, 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) 1, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec.7044, Business & Professions Code). I hereby affirm under penalty of perjury one of the following three 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. 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 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 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. 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 to building construction, and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We) agree to save -nify and keep harmless the City of Cupertino against liabilities, judgments, 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 source regulations per the Cupertino Municipal Code, Section 9.18. Signature Date 14380 OKA LN LOS GATOS, CA 95032 DATE ISSUED: 08/16/2011 PHONE NO: (408)356-4943 BUILDING PERMIT INFO: BLDG r- ELECT r— PLUMB MECH f— RESIDENTIAL r COMMERCIAL JOB DESCRIPTION: TEMP POWER POLE 20AMP GFIC;METER RELEASE REQUEST Sq. Ft Floor Area: I Valuation: $100 APN Number: 32602026.00 1 Occupancy Type: PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS F OM LAST ALL D INSPECTION. Issued by: ell I f/ � Date: RE -ROOFS: 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. Signature of Applicant: Date: ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER HAZARDOUS MATERIALS DISCLOSURE I have read the hazardous materials requirements under Chapter 6.95 of the California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Section 25532(x) should I store or handle hazardous material. Additionally, should I use equipment or devices which emit hazardous air 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 Health &Safety Code, SKtiogs 25505, 25533, and 25534. Owner Date• l CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of work's for which this permit is issued (Sec. 3097, Civ C.) Lender's Name Lender's ARCHITECT'S DECLARATION I understand my plans shall be used as public records. Licensed Professiona GENERAL PERMIT APPLICATION - - COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-32-98 • FAX (408) 777-3333 - buildinG(acuoertino.org I cad vl LZ ❑PLUMBING ❑NECHANICAL ❑ELECTRICAL ❑MISCELLANEOUS I PROJECT ADDRESS 1 1) 9/ � c— 1c. 7A--NI./o OWNER NAME �/p PHONE `_7AIL STREET ADDRESS v t L� CITY, STATE ZIP C, r� &_w /rte FAX /////��,9/>1 CONTACT NAME , , V `, /J�/� PHONE L , ` J E-MAIL STREET ADDRESS/ © IJ% CITY S TE FAX ❑ OWNER ❑ OWNER.BUILDER ❑ OWNER AGENT VCONTRACTOR ❑CONT%ACTORAGENr ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR LIC S NUMBER LIC79E TY3E BUS. LIC # COMPAINY NAME E-MA1L FAX STR.= ADDRESS CrrY, STATE. ZIP ®S ! OS 7M,6 ARCHITECT/SNG11,T ER NAME LICENSE NUMBER BUS. I1C # COMPANY NAME ' E -MAL FAX STREET ADDRESS CITY, STATE, PHONE JSE OF ❑ SFD or DUPLEX ❑ MULTI -FA -NM- BUII-DING: ❑ COMMERCIAL PROTECT IIJ WII DLAND ❑ YES URBAN INTERFACE AREA ❑ NO PROJECT W ❑ YES FLOOD ZONE ❑ NO IS THE BLDG AN ❑ YES EICHEEBR HOME? ❑ NO DESCRIPTION OF WORK elf TOTAL VALUATION: - RECEIVED BY: By my signature below, I certify to each of the following:,,p1m the property owner or authorized agent to act on the property owner's behalf. I have read this application and the information I bav r ide is corre .,� hav the criptiou of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating b dine ons 'on` I au n gntatives of Cupertino to enter the above -identified property for inspection pulposes. Signature of ApplicandAgen Date: �J "�y ` � C SUPPLEMENTAL INFOPNIATION REQUIRED OFFICE USE ONLY ❑ OVER-THE-COUNTER a ❑ EXPRESS U w U ❑ STANDARD ❑ LARGE ❑ MAJOR JL1FPMascApp_2011.doc revised 06/21111 CITY OF CUPERTINO IMP FCTTMAT(lR — RITII.iIIN(i' DIVI4ION APPLIANCE / EQUIP TYPE ADDRESS: 22140 hibiscus DATE: 08/16/2011 REVIEWED BY: larrys UNITS APN: BP#: "VALUATION: $0 PERMIT TYPE: Electrical Permit PLAN CHECK TYPE: Alteration / Addition / Repair PRIMARY SFD or Duplex USE: Amps PENTAMATION 1 REAP14 PERMIT TYPE: WORK $44.00 SCOPE PME Permit Fee: APPLIANCE / EQUIP TYPE FEE ID MISC ITEMS QTY UNITS BP FEES Temporary Power 1 ERT<200 $0.00 100 Amps $44 $44.00 PME Unit Fee: PME Permit Fee: $44.00 $0.00 Work Without Permit? 0 Yes No $44.00 Travel Documentation Fee: 1 TRA VDOC Strong Motion Fee: $0.00 i Select an Ad nistrative Item $0.00 Bldg Stds Commission Fee: SUBTOTALS: $132.00 $0.00 TOTAL FEE: $132.00 TOTALS: $44.00 n -,r -i;- il.J.ln nssi nro n"lv nn octimn/e rnntart the Dent for addn'l info. ♦V! /i. ! /{GJG GGu u• c •iasocu vs ••s .. .............. ... ... FEE ITEMS (Fee Resolution] ...�--.. -' �' --------- ------ --- - - FEE QTY/FEE MISC ITEMS PME Plan Check: $0.00 $44.00 PME Unit Fee: PME Permit Fee: $44.00 $0.00 Work Without Permit? 0 Yes No $44.00 Travel Documentation Fee: 1 TRA VDOC Strong Motion Fee: $0.00 i Select an Ad nistrative Item $0.00 Bldg Stds Commission Fee: SUBTOTALS: $132.00 $0.00 TOTAL FEE: $132.00 Revised: 07/04/2011