13020038 CITY OF CUPERTINO BUILDING PERMIT
TTT TD
BUILDING ADDRESS: 10751 SANTA LUCIA RD CONTRACTOR:-ran--%BE PERMIT NO: 13020038
QED
OWNER'S NAME: MADAN,VIRANJIT S. SGT„ DATE ISSUED:02/08/2013
PHONE NO:
OWNER'S PHONE: 4084469633
❑ LICENSED CONTRACTOR'S DECLARATION
JOB DESCRIPTION: RESIDENTIAL COMMERCIAL
License Class Lic.# INSTALL(N) 100AMP METER,NEXT TO(E)200AMP
METER. NEW METER FOR EV STATION ONLY,
Contractor COMPLETELY
I hereby affirm that I am licensed under the provisions f C apter 9 INDEPENDANT WITH SEPARATE METER FOR PG&E
(commencing with Section 7000)of Division 3 of the Business&Professions PURPOSES
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 Valuation:$2000
performance of the work for which this permit is issued. Sq.Ft Floor Area:
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:34217090.00 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.I agree to comply with all city and county ordinances and state laws relatingrHIN 180 D RMIT ISSUANCE OR
to building construction,and hereby authorize representatives of this city to enter CALLED INSPECTION.
upon the above mentioned property for inspection purposes. (We)agree to save O
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which ma rue against said City in consequence of the Date:granting of this p ' . itionall the ap licant understands and will complywith all non-poi t sou r gu do er a Cu rtino Municipal Code,Section
9.18. RE-ROOFS:Signature Date be inspected prior to any roofing material being installed.If a roof is
ut first obtaining an inspection,I agree to remove all new materials for
nspec .
❑ OWNER-BUILDER DECLARATION Signature of Applicant: Date:
I hereby affirm that I am exempt from the Contractor's License Law for one of
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) HAZARDOUS MATERIALS DISCLOSURE
1,as owner of the property,am exclusively contracting with licensed contractors to
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 A t Quality Management District I
performance of the work for which this permit is issued. will maintain compliance with the Cup tino unicipal Code,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by
the Health&Safety Code,Sect' 5 0 , �3, 34.
Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agent: Date:
permit is issued.
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 CONSTRUCTION LENDING AGENCY
Compensation laws of California. If,after making this certificate of exemption,I
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
work's for which this permit is issued(Sec.3097,Civ C.)
forthwith comply with such provisions or this permit shall be deemed revoked. Lender's Name
APPLICANT CERTIFICATION Lender's Address
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
upon the above mentioned property for inspection purposes.(We)agree to save ARCHITECT'S DECLARATION
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records.
granting 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
/4GENERAL PERMIT APPLICATION M E P
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION O�
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 O�
CUPERT{NO
(408)777-3228• FAX(408)777-3333• building(d)cuoertino.orq M 'SIC
[:1 PLUMBING ❑MECHANICAL F91FLECTRICAL ❑MISCELLANEOUS
PROJECT ADDRESS APN#
OVVNERNAME LI A Dpi N, PHONE 4Og-��" l� � E L raG'j C;0 /�✓�
STREET ADDRESS CITY, STATE,ZIP FAX
CONTACT NAME PHONE E-MAIL
STREETADDRESS CITY,STATE, ZIP F-°x
❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME LICENSE NU-MBE LICE'SE TYPE BUS.LIC#
COMPANY NAME E- IL F
Jo +` Lac
STREETCTF T IP PHONE
'_jkdi 2!-� -Ch 2
ARCHITECT/ENGLNEER NAME LICENSE NUMBER BUS. IC#
COMPANY NAME. E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF ❑SFD or DUPLEX ❑ MULTI-FAMILYTURBAN
PROJECT IN WILDLAN'D ❑ YES PROJECT IN ❑YES IS THE BLDG AN ❑ YES
BUILDING: ❑COMMERCIAL INTERFACE AREA ❑ NO FLOOD ZONE ❑NO EICHLER HOME? ❑NO
DESCRIPTION OF WORK
$1 ALi-I EIS cv vv A,-,, - T�
�- c, 1'`'I,E 7-- 7v S , LI P01" Z-a r
TOTAL VALUATION:
By my signature below,I certify to ea of e foll mg- I t prop own r or authorize nt to act on e property owne' . I have read this
application and the information I hav pr ded's o t. ave ead t e Descrip ion of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating t din o orize epresen ves of Cupertino to enter the above-i ntifi property for inspection pu@oses.
Signature of Applicant/Agent: Date:
OL
SUPPILENfENT RMATIgWREQVIRED OFFICE USE ONLY
>41-ER-THE-COUNTER
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1,EPAfiscApp_2011.doc revised 06/21/11
CITY OF CUPERTINO
FEE ESTIMATOR—BUILDING DIVISION
ADDRESS: 10751 SANTA LUCIA RD DATE: 02/08/2013 REVIEWED BY: MELISSA
APN: 342 17 090 BP#: "VALUATION: $2,000
*PERMIT TYPE: Electrical Permit PLAN CHECK TYPE: Alteration/Addition/ Repair
PRIMARY PENTAMATION 1 REAP2
USE: SFD or Duplex PERMIT TYPE:
WORK INSTALL N 100AMP METER NEXT TOE 200AMP METER. NEW METER FOR EV STATION
SCOPE ONLY, COMPLETELY INDEPENDANT WITH SEPARATE METER FOR PG&E
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Services 1 BELEC200 100 Amps $45
TOTALS: $45.00
t��h. 1i,rri C "rh 1'/<«��/�-�'«+��{ �.�'L',� Elec.Plan Check 0.0 hrs $0.00
bleclt. 1'8Yf1N1I`.>c' I xrrn7. 1 crr,ft 1 <: Elec.Permit IEPERMIT
Orber l'1rimb Irr Other Elec.Insp. 0.0 hrs $45.00
O7ltcr alcc/�. /resp- r'1'
ile�rh.ltisp. 1 �e
Ph,ritb. 1nsp. t c�a; Glee.Ct7", 1"
NOTE:This estimate does not include fees due to other Departments(Le.Planning,Public Works,Fire,Sanitary Sewer District,School
District,etc.). These fea are based on the preliminary information available and are only an estimate. Contact the Dept-for addn'l info.
FEE ITEMS (Fee Resolution 11-053 Eff: 7%1112) FEE QTY/FEE MISC ITEMS
Plan Check Fce:
.5'lippl. PC`Fee
PME Plan Check: $0.00
Perinrt Fec.,:
Sttp/, Fnsp ['ee
PME Unit Fee: $45.00
PME Permit Fee: $45.00
Corzsrr-uction las:
Administrative Fee: ]ADMIN $42.00
Work Without Permit? 0 Yes Q No $0.00
,IdV(,11h<rcl Pl arming Fees:
Travel Documentation Fee: ITRA VDOC $45.00
Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $1.00
SUBTOTALS: $178.50 $0.00 TOTAL FEE: $178.50
Revised: 01101/2013
Building Department
City Of Cupertino
10300 Torre Avenue
Cupertino,CA 95014-3255
Telephone: 408-777-3228
C U P E RT I N O Fax: 408-777-3333
CONTRACTOR/ SUBCONTRACTOR LIST
JOB ADDRESS: PERMIT#
OWNER'S NAME: / PHONE#
GENERAL CONTRACTOR- p BUSINESS LI ENSE#
ADDRESS: CITY/ZIPCODE:
*Our municipal code requires all businesses working in the city to have a City of Cupertino busin ss license.
NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE
GENERAL CONTRACTOR AND ALL SUBCONTRACTORS 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
T'
/Contr for gignature Date