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10080198 CITY OF CUPERTINO BUILDING PERMIT ILDING ADDRESS: 21702 LINDY LN CONTRAC"COR: PERMIT NO: 10080198 6, DATE ISSUED:08/27/2010 VNER'S NAME: PADMAJA GOGINEN[ PHONE NO: VER'S PHONE: 4082037093 ' LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG F ELECT r– PLUMB r ense Class Li,# ��7� �� MECH RESIDENTIAL COMMERCIAL r ntractor e- �•x,11 ti Date Ir JOB DES/'RIPTION:WINDOW REPLACEMENT OF 7 WINDOWS,FIVE ARE LIKE ereby affirm that I am licensed under the provisions of Chapter 9 FOR �mmencing with Section 7000)of Division 3 of the Business&Professions LIKE&TWO(2)TO RE-SIZE FROM TOP TO BOTTOM BY de and that my license is in full force and effect. l'(OK'D BY 3S IN PLANNING) Hereby affirm under penalty of perjury one of the following two declarations: ave and will maintain a certificate of consent to self-insure for Worker's impensation,as provided for by Section 3700 of the Labor Code,for the rformance of the work for which this permit is issued. Lave and will maintain Worker's Compensation Insurance,as provided for by etion 3700 of the Labor Code,for the performance of the work for which this Sq.Ft Floor Area: Valuation:54200 :rmit is issued. cn J t APPLICANT CERTIFICATION arc Occu Type: :ertify that I have read this application and state that the above information is APN Number:35624035.00 Occupancy YP : orrect.I agree to comply with all city and county ordinances and state laws relating building construction,and hereby authorize representatives of this city to enter )on the above mentioned property for inspection purposes. (We)agree to save demnify and keep harmless the City of Cupertino against liabilities,judgments, PERMIT EXPIRES IF WORK IS NOT STARTED )sts,and expenses which may accrue against said City in consequence of the WITHIN 180 DAYS OF PERMIT ISSUANCE O 2nting of this permit. Additionally,the applicant understands and will comply ith all non-point source regulations per the Cupertino Municipal Code,Section 180 DAYS FROM LAST CALLED INSPECTION. 18. ignature U. r e_ 1. Date GS b-e` Issued b):._ �2-s��—� Date: 7 lU _ OWNER-BUILDER DECLARATION hereby affirm that I am exempt from the Contractor's License Law for one of RE-ROOFS: he following two reasons: All roofs s call be inspected prior to any roofing material being installed.If a roof is ,as owner of the property,or my employees with wages as their sole compensation, installed%�ithout first obtaining an inspection,I agree to remove all new materials for vill do the work,and the structure is not intended or offered for sale(Sec.7044, inspection 3usiness&Professions Code) Signature )f Applicant: Date: ,as owner of the property,am exclusively contracting with licensed contractors to ;onstruct the project(Sec.7044,Business&Professions Code). ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER f hereby affirm under penalty of perjury one of the following three Ieclarations: f have and will maintain a Certificate of Consent to self-insure for Worker's HAZARDOUS MATERIALS DISCLOSURE -ompensation,as provided for by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. I have read the hazardous materials requirements under Chapter 6.95 of the Californi i Health&Safety Code,Sections 25505,25533,and 25534. I will maintain [have and will maintain Worker's Compensation Insurance,as provided for by compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health& Section 3700 of the Labor Code,for the performance of the work for which this Safety Code,Section 25532(a)should I store or handle hazardous material. permit is issued. Addition illy,should I use equipment or devices which emit hazardous air I certify that in the performance of the work for which this permit is issued,I shall contamir ants as defined by the Bay Area Air Quality Management District I will not employ any person in any manner so as to become subject to the Worker's maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the Compensation laws of California. If,after making this certificate of exemption,I Health 8 Safety Code,Sections 25505,25533,and 25534. become subject to the Worker's Compensation provisions of the Labor Code,I must Owner o,authorized agent: forthwith comply with such provisions or this permit shall be deemed revoked. a� Date: APPLICANT CERTIFICATION CONSTRUCTION LENDING AGENCY I certify that I have read this application and state that the above information is I hereby iffinn that there is a construction lending agency for the performance of work's correct.I agree to comply with all city and county ordinances and state laws relating for whicl this permit is issued(Sec.3097,Civ C.) to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes.(We)agree to save Lender': Name ',,nnify and keep harmless the City of Cupertino against liabilities,judgments, Lender';Address ,and expenses which may accrue against said City in consequence of the gi.ating of this permit.Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code,Section ARCHITECT'S DECLARATION 9.18. I undersi and my plans shall be used as public records. Signature Date License i Professional CITY OF CUPERT::NO RECENT NUMBER: BS000011309 RECEIVED BY: PAT PAYOR: SEAN WEIBY TODAY'S DATE: 08/27/10 REGISTER DATE: 08/27/10 TIME: 11:21 4 1BCBSC 10080198 $1.00 1BSEISMICR 10080198 $ .50 1WINREP 10080198 $380 .00 BUSINESS LICENSE TAX SEAN WEIBY $114 .00 ----------- ---- TOTAL DUE: $495 .50 CASH $495 .50 REF NUM: TENLERED CHANGE $455 .50 $. 00 _ (1 CITY OF C UPE RTIN O CUPIk INO GENERAL BUILDING PERMIT APPLICATION FORM Date: Building Address: Mailing Address (if different fr building address). Are Hazardous Materials being used as part of this project? Yes No HOA: xterior work onlYes ❑ No If es, ro Phone#: e letter from HOA Owner's Name: t V �� i Contractor: Phone: v,8- q&[>- L,)-S 1 Fax: Contractor License#: b Cupertino Business License#: Phone: Contact: Fax: Residential Commercial Job Description: t.0 I�J G l.e inr vy Building Permit Info: Bld L Elect ❑ Plumb ❑ Mech 11 Occupancy Type: Type of Construction (Usage Class): �-` II/III/V-A F-1II/III B, IV-HT,V-B 2-� ��"` 2� L 1-A, 1-B ❑ Valuation: Square Footage: � ov Project Size: Ex ress []--Standard ❑ Lar e ❑ v1a'or ❑ Green Building: Please complete relevant portion of the Green B ' ding/LEED Checklist & attach it to the application or if applicable, inch ide in plan set& the sheeex. 'oints Achieved: For help, contact Build it Green at www.builditgreen.or 7 Revised 07/14/09 ' 3 CITY OF CUPEF.TINO FEE ESTIMATOR—BUILDING DIVISION ADDRESS: DATE: REVIEWED.BY: APN: BP#: `VALUATION: $4,200 9;�PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration/Addition/Repair PRIMARY PENTAMATION USE: SFD or Duplex COUNTER l'es No PERMIT TYPE: A t� WORK SCOPE OCCUPANCY TYPE: TYPE OF FLR AREA PC FEES PC FEE ID BP FEES BP FEE ID CONSTR. s•f• R-3 (Custom) II-B,111-B,IV,V-B 0 $0.001 $0.00 M f tl $0.00 -0- TOTALS: 0 $0.00', .y . +a+JC1Cif uyw k # +, "' , sD v A�k r • r ..c5' ; ++6. r r •,, s;. $i. 1ftv:` "Lw(hcrk Phimh_ Plum C'ht'r! f7<<'_ Plan Cherck ;1drr.h l' r'nril P<>r Flwnh. Pcrn;it ('Phar PlurrrH lros/� Other L'iec_ fay, Pl lmh NOTE: Thesefees are based on the preliminary in ormation available 2nd are only an estimate. Contact the Dept-for addn 7 info. 7FEE ITEMS(Fee Resolution 09-051 Eff. 7'1;70) FEE Q'TY/FEE MISC ITEMS Plan Check Fee: $0.00 7 # Window/Sliding Glass Door Suppl. PC Fee: 0 Reg. © OT 0.0 hrs $0.00 $380.00 I W&REP Replacement PME ::j Plan Check: $0.00 Permit Fee: $0.00 Suppl. Insp.Fee4 Reg. 0 OT 0.0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 Luii•,lrtrtlt�r1 1�Lti Acoustical Fee: 0 Yes (F) No $0.00 Work Without Permit? 0 Yes 0 No $0.00 Planning,Fee: $0.00 Select a Non-Residential 0 Building or Structure o 1rai ,! 0ocruttcrrtfuliun Fues: 7--=_ Strong, Motion Fee: IBSEISMICR $0.50 Select an Administrative Item Bldg,Stds Commission Fee IBCBSC $1.00 'vn> `i.3a (� $381.50 , �`' Fy� i`>�AI $1.50 E$380.00 Revised: 8/17/2010 c 5 r j f ?a o s x 7 m G (ka, IOC - � cr crp Tj rr W 55 I > O NO n JAY c, r O C } E CP� G G r. � ' v � 0 cS ti ks -- CC, j ^ S Al- 1 � � rQ, VAcy A d � - 1 f Building Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014-3255 Telephone: 408-777-3228 CUPERTINO Fax: 408-777-3333 CONTRACTOR/ SUBCONTRACTOR LIST JOB ADDRESS: i'7o2 PERMIT# OWNER'S NAME: _ PHONE# l/ - 1- GENERAL CONTRACTOR: BUSINESS LICENSE# ADDRESS: 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 CONTRACTOR AND ALL SUBCONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE. I am not using any subcontractors: �� '^ t" p 2 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