11050008 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10153 COLBY AVE CONTRACTOR:DTHN CONSTRUCTION PERMIT NO: 11050008
CORP
OWNER'S NAME: GOPAL VENUGOPAL 1390 FRENCH CT DATE ISSUED:05/02/2011
'ER'S PHONE: 4083867310 MILPITAS,CA 95035 PHONE NO:(650)595-6912
❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class Lie.# & 7ZQ /
MECH RESIDENTIAL COMMERCIAL
Contractor D ' 'j& W" ate a
I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:SERVICE UPGRADE TO 100AMP
(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:$1200
I have and will maintain Worker's Compensation Insurance,as pro r by
Section 3700 of the Labor Code,for the performance of the work whic this
permit is issued. � APN Number:31628045.00 Occupancy Type:
APPLICANT CERTIFICATION
I certify that I have read this application and state that the abov info ion is
correct.I agree to comply with all city and county ordinances an e 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 f
with all non-point source regulations per the Cupertino Municipal Code,Section Issued by: Date:r,
`
9.18.
Signature Date
RE-ROOFS:
i_ 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:
I,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)
I,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. 1 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(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 Municipal Code,Chapter 9.12 and the
[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 Owner authol6zed agent: O �\�
Compensation laws of California. If,after making this certificate of exemption,I Date:
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 Aork'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
it' --►nify and keep harmless the City of Cupertino against liabilities,judgments, ARCHITECT'S DECLARATION
and expenses which may accrue against said City in consequence of the
&—aing of this permit.Additionally,the applicant understands and will comply I understand my plans shall be used as public records.
with 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 . . . . . . . . : 31628045. 00
DATE ISSUED. . . . . . . : 05/02/2011
RECEIPT #. . . . . . . . . : BS000013349
REFERENCE ID # . . . : 11050008
SITE ADDRESS . . . . . : 10153 COLBY AVE
SUBDIVISION . . . . . .
CITY . . . . . . . . . . . . . . CUPERTINO
IMPACT AREA . . . . . .
OWNER . . . . . . . . . . . . : GOPAL VENUGOPAL
ADDRESS . . . . . . . . . . : 10153 COLBY AVE
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
RECEIVED FROM . . . . : DTHN CONSTRUCTION
CONTRACTOR . . . . . . . : NGUYEN NAM LIC # 24888
COMPANY . . . . . . . . . . : DTHN CONSTRUCTION CORP
ADDRESS . . . . . . . . . . : 1390 FRENCH CT
CITY/STATE/ZIP . . . : MILPITAS, CA 95035
TELEPHONE . . . . . . . . : (650) 595-6912
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
-ADMIN HOURS 0 .50 39. 00 0. 00 39. 00 0 .00
1BCBSC VALUATION 1,200 .00 1. 00 0. 00 1 .00 0. 00
1BSEISMICR VALUATION 1,200 . 00 0. 50 0. 00 0 .50 0. 00
lEPERMITFE FLAT RATE 1. 00 42. 00 0 . 00 42 .00 0. 00
1ERT<200 UNITS 1. 00 42 . 00 0 . 00 42 .00 0. 00
1TRAVDOC FLAT RATE 1. 00 42 . 00 0 . 00 42 . 00 0. 00
---------- ---------- ---------- ----------
TOTAL PERMIT 166 .50 0. 00 166 .50 0.00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CASH 166. 50
---------------
TOTAL RECEIPT 166 .50
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
103 UFER 304 ROUGH ELECTRICAL
505 FINAL ELECTRICAL
CITY OF CUPERTINO
FEE ESTIMATOR-BUILDING DIVISION
ADDRESS: 10153 Colby ave. DATE: 05/02/2011 REVIEWED BY: bobs.
APN: BP#: `VALUATION: 1$1,200
"PERMIT TYPE: Electrical Permit PLAN CHECK TYPE: Alteration/Addition/ Repair
PRIMARY SFD or Duplex PENTAMATION 1 REAP2
USE: PERMIT TYPE:
WORK service upgrade to 100 am
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Services 1ERT<200 100 Amps $42
TOTALS: $42.00
Elec.Plan Check 0.0 hrs $0.00
Elec.Permit Fee: IEPERMIT
Other Elec.Insp. El hrs $42.00
NOTE: Thesefees are based on the preliminary information available and are only an estimate. Contact the De t or addn'1 info,
FEE ITEMS (Fee Resolution 09-051 Bf. b"I 0) FEE QTY/FEE MISC ITEMS
PME Plan Check: $0.00
PME Unit Fee: $42.00
PME Permit Fee: $42.00
Work Without Permit? 0 Yes No $0.00
Travel Documentation Fee: ITRA VDOC $42.00 A
Stronp,Motion Fee: IBSEISMICR $0.50 0.5 hrs Admin./Clerical Fee
Bldg Stds Commission Fee: 1BCBSC $1.00 $39.00 (ADMIN
SUBTOTALS: $127.50 $39.00 TOTAL FEE': $166.50
Revised: 04/29/2011
L,�5 o
GENERAL PERMIT APPLICATION MEP
COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255
(408)777-3228• FAX(408)777-3333•building(cDcuRertino.or4 misc
CUPERTINO
❑PLUMBING ❑MECHANICAL r ELECTRICAL ❑MISCELLANEOUS
PROJECT ADDRESS APN# r'
OWNER NAME t f t 1 PHONE -
6
6 w)
EMAIL
STREET ADDRESS , �� STT 7;
53
CONTACT NAME PHONE E-MAIL
STREET ADDRESS CITY,STATE,ZIP FAX
Cl OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAMELICENSE ER LICITE TYPE BUS.LIC#
p- , C. Y VN 6
COMPANY NAME 7 E-MAIL FAX
STREET ADDRESS CTIY,STATE,ZIP PHONE
ARCHTTECTIENGUMER NAME LICENSE NUMBER BUS.LIC#
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
3E OF ❑ SFD or Duplex ❑ Multi-Family PROJECT IN WILDLAND PROJECT IN
STRUCTURE: ❑ Cormnercial URBAN INTERFACE AREA ❑ Yes ❑ No FLOOD ZONE ❑ Yes ❑ No
DESCRIPTION OF WORK
n t.fCs
ep
TOTAL VALUATION: Am
By my signature below,I certify to each of the following: 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 have provided is correct. I 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 purposes.
r
Signature of Applicant/Agent: Date:
SUPP NTg MFORMATION REQUIRED `" y'
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MEPMiscApp_201I.doc revised 03/16/11