12100193 (2) CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10425 TONITA WAY CON'I'RACI'OR:ALI'S CONSTRUCTION& PERMITNO: 12100193
REMODELING
OAVNER'S NAME: NEELIKA CHOUD14URY 681 E BROKAW RD DATE ISSUED: 10/262012
OWNER'S PHONE: 4082069378 SAN JOSE,CA 95112 PHONE NO:(+08)898-6474
❑ LICENSED CON'1'RACFOR'S DECLARATION
BUILDING PERMIT INFO: BLDG r ELECT❑ PLUMB Fi
License Class Lie.4 _
, ) NIECII r RESIDENTIAL Ci COMMERCIAL r
Contractor Datc Z
I hereby affirm that I am licensed under the provisions o Chapter 9 JOB DESCRIPTION: INSTALLA'T'ION OFTEMPORARY POW17R POLE 200 AMT'S
(commencing with Section 7000)of Division 3 of the Business&Professions
Code and that my license is in full force and effect.
1 hereby affirm under penalty of perjury one of the following two declarations:
I have and will maintain a eenificate 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,\rea: Valuation:$I000
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. AI IN Number:35914009.00 Occupancy Type:
APPLICA\I'CERTIFICATION
I certify,that I have read this application and state that the above information is
correct.l 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 18U DAYS FROM LAST CALLED INSPECTION.
costs,and expenses which may accrue against said City inconsequence of the
granting of this permit. Additionally,the applicant understands and will comply /,/ /
with all non-point source egulations per the Cupertino Municipal Code,Section Issued by: / A/ ��/G/� Date:�lf-a(�•��-
9.18.
Signature Date
Rh;ROOFS:
❑ O\J'N , 11I1,DER DF;CLARATION All roofs shall be inspected prior to any roofing material being installed.Ira roof is
installed without first obtaining run 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(See.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 BE I'ER
construct the project(Sec.7044,Business&Professions Code).
hereby affirm under penalty of perjury one of the following three IIA%ANDOIIS MATERIA S 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. 1 will maintain
Compensation,as provided for by Section 3700 of the Labor Code,for the compliance with the Cupertino Jtunicipal Code,Chapter 9.12 and the Ihealth&
performance ofthe work for which this permit is issued. Safety Code,Section 25532(x)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
permit is issued, maintain compliance with the Cupertino Jtunicipal Code,Chapter 9.12 and the
1 certify that in the performance of the work for which this permit is issued,IShall Ilcalth\Safety Code.Sections 25505,25533,and 25534./
6��
not employ any person in any manner so as to become subject to the Worker's Ow thorized agent: — t „U&/„ .
Compensation laws ofCalifomin. If,after making this certificate of exemption,I t Date; 1
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. CONS'IRIICI'ION LENDING AGENCY
I hereby aff in thm there is a construction lending agency for the performance of work's
APPLICANT CISRTIFIC ATION 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,
costs,and expenses which may acerae against said City in consequence of the ARCIIITE.CT'S HECLARATION
granting of this permit.Additionally,the applicant understands and will comply I understand my plans shall be used as public records.
with all non-paint source regulations per the Cupertino Municipal Code,Section
9.18. Licensed Professional
Signature Date
GENERAL PERMIT APPLICATION M E P
COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 '\ee�p A I S C
CUPERTINO (408)777-3228• FAX(408)777-3333 • buildina(EDCUDeaino.ora /
�-y aia�i9�
❑PLUMBING ❑MEC[iANICAL I(iL ELECTRICAL ❑MISCELLA,^IEGllS
PROJECT ADDRESS T � r. 1 I APN.t 3�9• Al• Jp�
OWNER NAME J I G vJ`� PHONEY,
B'd�b
STAEETADDRESS CITY, STATE,ZIP /`'/i Tji✓O LA FAX
CONTACT NAME 70\�ry\ VLYVI PH0NE�0 -- p. -74
EMM.
-M .
(C) CITY.STATE, ZIP G fCA_/ �151 � 21FAX d — oqqo
❑OWNER ❑ OWNER-BUIDER ❑ OWNER AGENT CONTRACTOR ❑CONTRACTOR AGENT ❑ AACHMCT ❑ENGPEER ❑ DEVEIAPER ❑ TENANT
CONTRACTORNAME / Lwri LICENSE NUMBER q O� LICENSE TYPE BUS.LIC0^'7 O%„-7
COMPANY NA.Y¢ U 1 L "A
'MAiL G - FAX
AI`o_ (O(/�Q O
STREET ADDRESS I CITY.STATE,ZIP nHON'E'1 Y'1�1�—�� (�
ARC:nE.CT/ENGINEER NAME / LICENSE NUMBER h BUS.LICT0J
COMPANY NAME' (y E-MAIL FAX
STREET ADDRESS I CITY,STATE,ZIP PHONE
USE OF FD.DUPt CY ❑ MULTI-FAMILY I PROJECT DJ WD-DI-AND ❑ YES I PROTECTIN ❑YES I [S i}SLDGAN ❑ YES
BI1ItDWG: �COMMERCLLL URBAN INTERFACE AREA NO FLOOD ZONE NO OCJLRHOMEJ NO
DESCRIPTION OF WORK
TOTAL VALUATION: /v UO -- RECEIVED BY: l�
i
By my signamm below,I certify to each of the'.Ilow'ag: i am the property owner or authorized agent to act on the property owner's behalf. 1 have mad this
applicaion and the information I have provid is rrect. I have read the Description of Work and verify it is actuate. I agree io comply with all applicable local
ordinances and sate laws relating m' •ilii co miction. I authorize representatives of Cupertino to enter the above-identified props try for inspection puiposes.
SignammofApplicant/Agenu ` Data. A)
P ENIENTAL MATION QUIRE OFFICE use ONLY
y OVER-THE.COUNTER
❑ EXPRESS
U
v ❑ STANDARD
U
❑ LARGE
❑ MAJOR
A,fEP.VucApp_2011.doc revised 06/21/11
CITY OF CUPERTINO
FEE ESTIMATOR - BUILDING DIVISION
ADDRESS: 10425 Tonita Way DATE: 10/26/2012 REVIEWED BY: Sean
APN: BP#: bw&r/ 3 'VALUATION: $1,000
*PERMIT TYPE: Electrical Permit PLAN CHECK TYPE: Alteration /Addition / Repair
PRIMARY SFD or Duplex PENTAMATION 1 REAP14
USE: PERMITTYPE:
WORT: Installation of temporary ower pole 200 amp).
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Temporary Power 1ERT<200 200 Amps $45
TOTA LS: $45.00
,Neth. Plan Check Phmhb. Plan Check Elec. Plan Check 1 0.0 1 hrs $0.00
Meth. Permit Fee: Plumb. Permit Fee: Elec. Permit Fee: IEPERMIT
Other Alech.Insp. Other Plumb Insp. Other Elec. Insp. 0.0 hrs $45.00
Mech.hap. Fee: Plumb. Gap.Fee: Elec.Ihsp. Fee:
NOTE: This estimatedoes not include jeer due to other Departments(i.e. Planting, Public Works, Fire,Sanitary Server District,School
District,etc.). These fees are based onthe relitninarp information available and are onl$,an estimate. Contact the Dept for addn7 info.
FEE ITEMS (Fee Resohaion 11-053 F_IT LI 12) FEE QTY/FEE MISC ITEMS
Plan Check Fee:
SuppL PC Fee
PME Plan Check: $0.00
Permit Fee:
Suppl. lnsp Fee
PME Unit Fee: $45.00
PME Permit Fee: $45.00
Consnvtction Tax:
Administrative Fee: !ADMIN $42.00
Work Without Permit? O Yes (E) No $0.00
Advanced Planting Fees:
Travel Documentation Fee: ITRA WOC $45.00 A
Stronu, Motion Fee: IBSEISA-IICR $0.50 Select an Administrative Item
131da Stds Commission Fee: IBCBSC $1.00
SUBTOTALS: $178.50 $0.00 TOTAL FEE: $178.50
Revised: 10/01/2012
Building Department
City Of Cupertino
10300 Torre Avenue
Cupertino, CA 95014-3255
Telephone:408-777-3229
C U P E RT I N O Fax: 408-777-3333
CONTRACTOR / SUBCONTRACTOR LIST
JOBADDRESS: PERMIT# D
OWNER'S NAME:: PHONE #
GENERAL CONTRACTOR: L ' /rl / BUSINESS LICENSE #
ADDRESS: &,el E 6 CITY/ZIPCODE:
*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 CON'T'RACTOR AND ALL S CONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO
BUSINESS LICENSE.
I am not using any subcontractors:
Ignature - Date
Please check applicable subcontractors an omplete 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