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09100063 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10175 VICKSBURG DR CONTRACTOR:NITIN KALJE PERMIT NO:09100063 OWNER'S NAME: NITIN KAUE 10175 VICKSBURG DR DATE ISSUED: 10/09/2009 ER'S PHONE: 4088650584 CUPERTINO CA,CA 95014-3318 PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG f— ELECT r— PLUMB License Class Lic.# MECH[_ RESIDENTIAL f— COMMERCIAL Contractor Date I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:RREPLACING DAMAGED PLATES OF (commencing with Section 7000)of Division 3 of the Business&Professions SUBFLOORING,ADD A Code and that my license is in full force and effect. BEAM,RE-DO THE TILES.REPAIR EXISTING FLOOR JOIST 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 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 Sq.Ft Floor Area: Valuation:$500 Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. APN Number:36907007.00 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 to building construction,and hereby authorize representatives of this city to enter PERMIT EXPIRES IF WORK IS NOT STARTED upon the above mentioned property for inspection purposes. (We)agree to save indemnify and keep harmless the City of Cupertino against liabilities,judgments, WITHIN 180 DAYS OF PERMIT ISSUANCE OR costs,and expenses which may accrue against said City in consequence of the 180 D YS FROM L T CALLED INSPECTION. 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• . Issued by: Date: Signature Date OWNER-BUILDER DECLARATION RE-ROOFS: All roofs shall be inspected prior to any roofing material being installed.If a roof is 1 hereby affirm that I am exempt from the Contractor's License Law for one of installed without first obtaining an inspection,I agree to remove all new materials for the following two reasons: inspection. 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, Signature of Applicant: Date: Business&Professions Code) I,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044,Business&Professions Code). ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER I hereby affirm under penalty of perjury one of the following three HAZARDOUS MATERIALS DISCLOSURE declarations: I have and will maintain a Certificate of Consent to self-insure for Worker's I have read the hazardous materials requirements under Chapter 6.95 of the Compensation,as provided for by Section 3700 of the Labor Code,for the California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain performance of the work for which this permit is issued. compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health& I have and will maintain Worker's Compensation Insurance,as provided for by Safety Code,Section 25532(a)should I store or handle hazardous material. Section 3700 of the Labor Code,for the performance of the work for which this Additionally,should I use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management District 1 will permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the I certify that in the performance of the work for which this permit is issued,I shall Health&Safety Code,Sections 25505,25533,and 25534. 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 Owner or thoriz d agent: U become subject to the Worker's Compensation provisions of the Labor Code,I must /� Date: -1 forthwith comply with such provisions or this permit shall be deemed revoked. - CONSTRUCTION LENDING AGENCY APPLICANT CERTIFICATION I hereby affirm that there is a construction lending agency for the performance of work's I certify that I have read this application and state that the above information is for which this permit is issued(Sec.3097,Civ C.) correct.I agree to comply with all city and county ordinances and state laws relating Lender's Name to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes.(We)agree to save Lender's Address nify and keep harmless the City of Cupertino against liabilities,judgments, c. and expenses which may accrue against said City in consequence of the ARCHITECT'S DECLARATION granting of this permit.Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code,Section I understand my plans shall be used as public records. 9.18. Licensed Professional Signature Date I l CITY OF CUPERTINO 4 ITEMS OF 4 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN 36907007 .00 DATE ISSUED. . . . . . . : 10/09/2009 RECEIPT #. . . . . . . . . : BS000008870 REFERENCE ID # . . . 09100063 SITE ADDRESS . . . . . : 10175 VICKSBURG DR SUBDIVISION . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . OWNER NITIN KALJE ADDRESS 10175 VICKSBURG DR CITY/STATE/ZIP . . . : CUPERTINO CA, CA 95014-3318 RECEIVED FROM . . . . : NITIN A KALJE CONTRACTOR LIC # *OWNER* COMPANY NITIN KALJE ADDRESS 10175 VICKSBURG DR CITY/STATE/ZIP . . . : CUPERTINO CA, CA 95014-3318 TELEPHONE . . . . . . . . FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- ---------- 1BCBSC VALUATION 500 . 00 1 .00 0 . 00 1 . 00 0 . 00 1BSEISMICR VALUATION 500. 00 0 .50 0. 00 0 . 50 0 .00 1INSPPAR HOURS 1. 00 126 . 00 0 . 00 126 . 00 0 .00 1TRAVDOC FLAT RATE 1 . 00 42 . 00 0 . 00 42 . 00 0 .00 ---------- ------ --- ---------- ---------- TOTAL PERMIT 169.50 0 .00 169.50 0 .00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CREDIT CARD 169 .50 VISA --------------- TOTAL RECEIPT 169.50 � CITY OF CUPERTINO ,SM ADDITION/REMODEL CUPEkTINO PERMIT APPLICATION FORM - APN # `> Date: 1 3�4 D 7p p'7. v 2- 1-110 "1 Is a 2" unit being added? Yes E] No F-1If yes, please fill out the permit application for 2" unit. Building Address: Mailing Address (if different from building address): Owner's Name: Phone# Z-1 C) Contractor: / Phone#:6 q 1 1 ��► �� "� l v V�-R Fax#: Contractor License#: Cupertino Business License#: Contact: Phone#: Fax#: Permit Info: Bldg. Elect. ❑ Plumb. ❑ Mech. ❑ Hillside ❑ Job Descriptio : � � ddi ' at is being added?(Be Specific): `(��'� c �1 What is being remodeled (not`#ncluding addition)? Remodel Includes Re-Roof. Yes ❑ No [Z If yes list number of squares Remodel Includes Structural: Yes ❑ No E] Do you have the pre-application planning approval? Yes ❑ No If yes, please provide a copy of your planning approval letter. Planners name: Square Footage: Addition: Porch: Deck: Garage: Detached Attached Remodel: Kitchen Bath Other Type of Construction (Usage Class): Occupancy Type: 1-A, 1-B ❑ II/III/V-A ❑ II/III B, IV-HT, V-B ❑ Valuation: Please check this box if the project is a second-story addition ❑ Project Size: Express ❑ Standard ❑ Lar e ❑ Major❑ Please complete relevant portion of the Green Building Checklist& attach it to the application or if applicable, Green Building Points Achieved: include in plan set& the sheet index. ***For Office Use Only*** Over-the-Counter 0 Revised 07/06/09 CITY OF CUPERTINO ADDITON/REMODEL FEE SCHEDULE Quantity Fee ID Fee Description Fee Group Permit Type Sq Ft 1 REMRES2 Remodel Residential B Greater than 1000 sq ft 1REMRES3 Remodel Residential B Greater than 2500 sq ft. 1REROOFRES Residential Re-roof Each B 100 SF REMODEL PLNCK ISTPLNCK(1-3 for Standard Plan Check B NOT FOR OVER THE remodel) COUNTER PLAN CKS. WINDOW/SLIDING 1R3SFDREM GLASS DOOR 1 WINREP Replacement windows B (ea 8 windows) 1 WINNEWNSTR New Window(non- B structural 1WINMEWSTR New Window (Structural B Shear Wall/Masonry) 1 WINBAYSTR Bay Window(Structural) B SKYLIGHTS 1R3SFDREM 1 SKYL<10 SF Skylight less than 10 sf B 1 SKYL>10SF Skylight greater than 10 B sf or structural 1STAIRS Stairs-first flight/ea addt'1 B 1 EPERMITFEE Electrical Permit Fee E 1 MPERMITFEE Mechanical Permit Fee M 1PPERMITFEE Plumbing Permit Fee P 1 ELCPLNCK Stand Alone Electric Pln E Ck (hourly) CITY OF CUPERTINO ADDITON/REMODEL FEE SCHEDULE Quantity Fee ID Fee Description Fee Group Permit Type Sq Ft 1 MECPLNCK Stand Alone Mechanical M Pln Ck(hourly 1PLMPLNCK Stand Alone Plumbing P Pln Ck (hourly) 1BCBSC Cal Bldg Standards B ALL PERMIT TYPES Commission Fee 1BSEISMICRE Seismic Residential B 1 TRAVDOC Travel & Documentation B 1BUSLIC Business License B