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11030003 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 23637 BLACK OAK WAY CONTRACTOR: - PERMIT NO: 11030003 OWNER'S NAME: SANJAY TANDON � DATE ISSUED:03/01/2011 NER'S PHONE: 6509693225 PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATION ( F_ f— ` , BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class C( © Lic.# 1 ` 2��Ly„2 MECH RESIDENTIAL COMMERCIAL Contractorpi I�C11[l% j �-eCsV►-i�, Date I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION: REPLACE EXTERIOR&INTERIOR LIGHT,SWITCHES& (commencing with Section 7000)of Division 3 of the Business&Professions RECEPTACLES PER 2010 CEC Code and that my license is in full force and effect. I hereby affirm under penalty of perjury one of the following two declarations: 1 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:$1320 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 APN Number:34256018.00 Occupancy Type: permit is issued. APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED correct. 1 agree to comply with all city and county ordinances and state laws relating WITHIN 180 DAYS OF PERMIT ISSUANCE OR to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We)agree to save 180 DA OM LAST CALLED INSPECTION. 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. Additionally,the applicant understands and will comply Issued by: Date:- with all non-point source regulations per the Cupertino Municipal Code,Section - 9.18. f� �L�A Date any r ROOFS: Signature U _ All roofs shall be inspected prior to any roofing material being installed. If a roof is installed without first obtaining an inspection,1 agree to remove all new materials for inspection. Li OWNER-BUILDER DECLARATION I hereby affirm that 1 am exempt from the Contractor's License Law for one of Signature of Applicant: Date: the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER 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 HAZARDOUS MATERIALS DISCLOSURE construct the project(Sec.7044,Business&Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the California Health&Safety Code,Sections 25505,25533,and 25534. I will I hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the declarations: Health&Safety Code,Section 25532(a)should I store or handle hazardous I have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally,should I use equipment or devices which emit hazardous Compensation,as provided for by Section 3700 of the Labor Code,for the air contaminants as defined by the Bay Area Air Quality Management District I performance of the work for which this permit is issued. will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sections 25505,25533,and 25534. Section 3700 of the Labor Code,for the performance of the work for which this 3 Date: permit is issued. Owner or authorized agent Y1')A_ 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 CONSTRUCTION LENDING AGENCY become subject to the Worker's Compensation provisions of the'Labor Code,I must I hereby affirm that there is a construction lending agency for the performance of forthwith comply with such provisions or this permit shall be deemed revoked. work's for which this permit is issued(Sec.3097,Civ C.) Lender's Name APPLICANT CERTIFICATION Lender's Address 1 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 nnify and keep harmless the City of Cupertino against liabilities,judgments, ARCHITECT'S DECLARATION s,and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records. graating of this permit.Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code,Section Licensed Professional 9.18. Signature Date 0 CITY OF CUPERTINO FEE ESTIMATOR— BUILDING DIVISION ADDRESS: 23637 black oak way DATE: 03/01/2011 REVIEWED BY: bobs. APN: BP#: ''VALUATION: 1$1,320 xPERMIT TYPE: Electrical Permit PLAN CHECK TYPE: Alteration/Addition / Repair PRIMARY SFD or Duplex PENTAMATION 1REAP11 USE: PERMIT TYPE: WORK re lace exterio # li htp and switches per 2010 CEC. SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Fixtures, Lighting 1BREMFIXT 1 # $63 Recep/Switch/Outlets 1 BREMRECEP 8 # $42 T- I -T TOTALS: $105.00 �T4'« " , ( ,f<;` Elec.Plan Check I 0.0 hrs $0.00 F/uIm f c v', P z:'i: Elec.Permit Fee: 1 EPERMIT Other Elea Insp. 0.0 hrs $42.00 NOTE: Thesefees are based on the preliminary information available and are only an estimate. Contact the De t or addn'l info. FEE ITEMS (Fee Resolution 09-0.51 Eff.71'1.%10) FEE QTY/FEE MISC ITEMS Man Chcc/ f'c F': .Supp/. PC/'c'c JPME Plan Check: $0.00 stapp1, hisp 1''cc PME Unit Fee: $105.00 PME Permit Fee: $42.00 C.e�rt.}tt'trciirlti 1 c7:t ,lc ouslical Work Without Permit? 0 Yes (F) No $0.00 Travel Documentation Fee: ITRAVDOC $42.00 Strong Motion Fee: 1BSEISMICR $0.50 Select an Administrative Item Bldg Stds Commission Fee: 1BCBSC $1.00 SUBTOTALS: $190.50 $0.00 TOTAL FEE:T $190.50 Revised: 01/15/2011 CITY OF CITY OF CUPERTINO GENERAL BUILDING CUPERTINO PERMIT APPLICATION FORM v 3000 3 APN# 3�4;� CO Date: 3/, 1 Building Address: Mailing Address (if different from building dress): Are Hazardous Materials being used as part of this project? Yes No HOA: (Exterior work only) Yes ❑ No'o If yes, provide letter from HOA If Residential is house an Eichler? Yes ❑ No If yes, needs planning approval. Owner's Nanle: Phone #: Contracto . Phone: 10 echl Fax: Contractor License #: G�O -cI lI l o3-(P Cupertino Business License #: Contact: Phone: - � Fax/e-mail: Residential Commercial ❑ Cl �- e.Oz.Cl rl (Yt _ Job Description: JPv.+0 sx n �e l✓`-T � ��ye� e v� c�i�.. 4.:��,C��nrk�v�b j' f�c2.�..Ci Qr �'— Building Permit Info: Bldg ❑ Elect Plumb ❑ Mech ❑ Type of Construction (Usage Class): Occupancy Type: 1-A, 1-B ❑ II/III/V-A ❑ II/III B, IV-HT, V-B V-171 Valuation: Square Footage: `)� Project Size: Counter ress ❑ Standard ❑ Large ❑ Major ❑ Green Building: Please complete relevant portion of the Green Building/LEED Checklist& attach it to the application or if applicable, include in plan set & the sheet index. Points Achieved: For help, contact Build it Green at www.buildit reen.or Revised 12/06/10 Building Department City Of Cupertino 10300 Torre Avenue Is Cupertino, CA 95014-3255 Telephone: 408-777-3228 Fax: 408-777-3333 CUPERTINO CONTRACTOR/ SUBCONTRACTOR LIST PERMIT# IF1111i'') 11 JOB ADDRESS: � PHONE# _G OWNER'S NAME: C J BUSINESS LICENSE# GENERAL CONTRACTOR: CITY/ZIPCODE: C ADDRESS: �` �" *Our municipal code requires all businesses working in the city to have a City of CupeSCHEDULEDI,UNTIL THE NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) OBTAINED A CITY OF CUPERTINO GENERAL CONTRACTOR AND ALL SUBCONTRACTORS BUSINESS LICENSE. "t I I I( I am not using any subcontractors: r��� Date Signa ure Please check applicable subcontractors and complete the following information: LICENSE # SUBCONTRACTOR BUSINESS NAME BUSINESS 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 Date Owner/Contractor Signature