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11050205 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 20804 GARDEN GATE DR CONTRACTOR:FEMEX PERMIT NO: 11050205 OWNER'S NAME: APURVA&KUMAR MEHTA 1821 S BASCOM AVE STE 258 DATE ISSUED:05/25/2011 OWNER'S PHONE: 4085008511 CAMPBELL,CA 95008 PHONE NO:(408)500-8511 CY LICENSED CONTRACTOR'S DECLARATIONr BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class Lic.# S�fCp l0 7 /� _ MECH RESIDENTIAL COMMERCIAL (> Contractor I �� ,nicer'_ Date l] I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:TEMP POWER POLE<200 AMP-FRONT OF PROPERTY (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:$350 I have and will maintain Worker's Compensation Insurance,as provided for by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. APN Number:32630038.00 Occupancy Type: APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is correct.I agree to comply with all city and county ordinances and state laws relating PERMIT EXPIRES IF WORK IS NOT STARTED to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We)agree to save WITHIN 180 DAYS OF PERMIT ISSUANCE OR indemnify and keep harmless the City of Cupertino against liabilities,judgments, 180 DA S FROM L T CALLED INSPECTION. costs,and expenses which may accrue against said City in consequence of the granting of this permit. Additionally,the applicant understands and will comply with all non-point sour gulations per the Cupertino Municipal Code,Section Issued by: Date: 9.18. /�-- Signature ` Date__$ li}-�( RE-ROOFS: 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) 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. 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 permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&Safety Code,Sections 25505,25533,and 25534. 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 Owner aut zed agent: Compensation laws of California. If,after making this certificate of exemption,I .r- 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 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, .,and expenses which may accrue against said City in consequence of the ARCHITECT'S DECLARATION .ing of this permit.Additionally,the applicant understands and will comply I understand my plans shall be used as public records. wan all non-point source regulations per the Cupertino Municipal Code,Section 9.18. Licensed Professional Signature __ Date CITY OF CUPERTINO 5 ITEMS OF 5 PERMIT RECEIPT OPERATOR: TraciC COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot : APN . . . . . . . . . 32630038 . 00 DATE ISSUED. . . . . . . : 05/25/2011 RECEIPT #. . . . . . . . . : BS000013566 REFERENCE ID # . . . : 11050205 SITE ADDRESS . . . . . : 20804 GARDEN GATE DR SUBDIVISION . . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . . OWNER . . . . . . . . . . . . : APURVA & KUMAR MEHTA ADDRESS . . . . . . . . . . : 20804 GARDEN GATE DR CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM . . . . : G FERNANDEZ CONTRACTOR . . . . . . . : GILBERTO FERNANDEZ JR LIC # 29722 COMPANY FEMEX ADDRESS . . . . . . . . . . : 1821 S BASCOM AVE STE 258 CITY/STATE/ZIP . . . : CAMPBELL, CA 95008 TELEPHONE . . . . . . . . : (408) 500-8511 FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- ---------- 1BCBSC VALUATION 350 . 00 1 . 00 0 . 00 1. 00 0 . 00 1BSEISMICR VALUATION 350. 00 0 .50 0 . 00 0 . 50 0 .00 1EPERMITFE 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 127 .50 0. 00 127. 50 0 . 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CREDIT CARD 127 .50 Visa 009532 --------------- TOTAL RECEIPT 127 .50 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 402 TEMPORARY POWER GENERAL PERMIT APPLICATION MEP COMMUNITY DEVELOPMENT DEPARTMENT- BUILDING DIVISION i 10300 TORRE AVENUE-CUPERTINO, CA 95014-3255 (408)777-3228 • FAX(408)777-3333•buking(acupertino.org misc CUPERTINO ❑PLUMBING ❑MECHANICAL R ELECTRICAL ❑MISCELLANEOUS PROJE ADDRESStSo 11 �N n �� C) C o� v w OWNERN �I J ^� 1►'1 PtT r 11 E M4 -ern STREET ADDRESS (V\ ,` CITY,STATE,ZIP FAX CUP 2iUD rci4- COMA 7 P ONE �`- �j I ET ti CQ V11 STREET ADDRESS �� CTTY, ATE ZIP FAX �1� 0 ❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT CONTRAR LICENSE ER LICEN TYPE BUS. H COMPANY NAME E-MAJL /� FAX . ( n STREET ADDRESS Z5$ CrrY, ATE ZIP r PHONE S r S. 462 ARCHTTECT/ENGINEER NAME LICENSE NUMBER BUS.LIC 4 COMPANY NAME V, E-MAM FAX STREET ADDRESS CITY,STATE,ZIP PHONE 'SE OF ❑ SFD or Duplex ❑ Multi-Family PROJECT rN WQ,DLAND PROJECT IN STRUCTURE: ❑ Commercial URBAN INTERFACE AREA ❑ Yes Cl No FLOOD ZONE ❑ Yes ❑ No DESCRIPTION OF WORK TOTAL VALUATION: 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 provid correct ve 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 ctio I authorize representatives of Cupertino to enter the above-identified property for inspection purposes. Signature of Applicant/Agent: Date: 7�J ZQ SUPPLEMENTAL INFORMA bra 1 1 MEPM1scApp_1011.doc revised 03/16/11 CITY OF CUPERTINO FEE ESTIMATOR-BUILDING DIVISION ADDRESS: DATE: 05/25/2011 REVIEWED BY: APN: BP#: "VALUATION: $350 R'PERMITTYPE: Electrical Permit PLAN CHECK TYPE: Alteration /Addition / Repair PRIMARY SFD or Duplex lex PENTAMATION 1 REAP14 USE: PERMIT TYPE: WORK SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Temporary Power 1 ERT<200 100 Amps $42 TOTALS: $42.00 Elec.Plan Check 0.0 hrs $0.00 Elec.Permit Fee: IEPERMIT Other Elec.Insp. 0.0 hrs 1 $42.00 NOTE: These ees are based on the preliminary information available and are only an estimate. Contact the Det or addn 7 info, FEE ITEMS (P'ee Resolution 09-051 F;tf 711/10) 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 Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $1.00 SUBTOTALS: $127.50 $0.00 TOTAL FEE: $127.50 Revised: 04/29/2011 Building Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014-3255 Telephone: 408-777-3228 U P E RT I N O Fax: 408-777-3333 CONTRACTOR/ SUBCONTRACTOR LIST JOB ADDRESS: PERMIT# OWNER'S NAME: PHONE# GENERAL CONTRACT R: Cn BUSINESS LICENSE# ADDRESS: I if 25 5. tom- ZS CITY/ZIPCODE: G C- 4,<W *Our municipal code requires all businesses working in the city to have a City of Cuperti o business license. NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE GENERAL CONTRACTOR AND ALL SUB NTRACTORS 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