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10050167 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 19780 DRAKE DR CON TRACTOR:TBD-TO BE DETERMINED PERMIT NO: 10050167 OWNER'S NAME: SANTANU SINHA DATE ISSUED:05/21/2010 JER'S PHONE: 4084461906 PHONE NO: LICENSED CONTRACTOR'S DECLARATIONr BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class Lic.# —7 9 R57 9 MECH[_ RESIDENTIAL I— COMMERCIAL� Contractor G0rt6Z- .9,0S7_ Date DS 2 Zd 10 I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:REMV&REPLC ALL FIXTURES,LOCATION STAYS (commencing with Section 7000)of Division 3 of the Business&Professions SAM';,RMDL MAS' BATH LIKE FOR LIKE(70SQ) Code and that my license is in full force and effect. i ER 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. 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 Sq.Ft Floor Area: Valuation:$5200 permit is issued. APPLICANT CERTIFICATION APN Number:31632012.00 Occupancy Type: 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 PERMIT EXPIRES IF WORK IS NOT STARTED indemnify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City in consequence of the WITHIN 180 DAYS OF PERMIT ISSUANCE OR granting of this permit. Additionally,the applicant understands and will comply :,80 DAYS FROM T CALLED INSPECTION. with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. 17 �rA91 /?,_ /0 �/� 4�" Issued by. Date: Signature /"u Date�� Z�/ L 1 J r1 L.1 OWNER-BUILDER DECLARATION / RE-ROOFS: I hereby affirm that I am exempt from the Contractor's License Law for one of All roofs shall be inspected prior to any roofing material being installed.If a roof is the following two reasons: insta led without first obtaining an inspection,I agree to remove all new materials for 1,as owner of the property,or my employees with wages as their sole compensation, inspc ction. will do the work,and the structure is not intended or offered for sale(Sec.7044, Business&Professions Code) Sign:Kure of Applicant: Date: I,as owner of the property,am exclusively contracting with licensed contractors to — construct the project(See.7044,Business&Professions Code). ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER I hereby affirm under penalty of perjury one of the following three declarations: HAZARDOUS MATERIALS DISCLOSURE 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 I have read the hazardous materials requirements under Chapter 6.95 of the performance of the work for which this permit is issued. California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain I 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 Safe y Code,Section 25532(a)should I store or handle hazardous material. Add:tionally,should I use equipment or devices which emit hazardous air permit is issued. cont tminants as defined by the Bay Area Air Quality Management District I will I certify that in the performance of the work for which this permit is issued,I shall mah tain compliance with the Cupertino Municipal Code,Chapter 9.12 and the not employ any person in any manner so as to become subject to the Worker's Health&Safety Code,Sections 25505,25533,and 25534. 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 Owner or authorized agent forthwith comply with such provisions or this permit shall be deemed revoked. _Date:6S j'L APPLICANT CERTIFICATION CONSTRUCTION LENDING AGENCY I certify that I have read this application and state that the above information is I her affirm 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 v hich this permit is issued(Sec.3097,Civ C.) to building construction,and hereby authorize representatives of this city to enter Lens ter's Name upon the above mentioned property for inspection purposes.(We)agree to save unify and keep harmless the City of Cupertino against liabilities,judgments, Lender's Address ,and expenses which may accrue against said City in consequence of the granting of this permit.Additionally,the applicant understands and will comply ARCHITECT'S DECLARATION with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. I unc erstand my plans shall be used as public records. Signature Date Licensed Professional CITY OF CUE ERTINO 3 ITEMS OF 4 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Iot: APN . . . . . . . . : 31632C12 . 00 DATE ISSUED. . . . . . . : 05/21/ 2010 RECEIPT #. . . . . . . . . BS000C10459 REFERENCE ID # . . . : 100501.67 SITE ADDRESS . . . . . : 19780 DRAKE DR SUBDIVISION . . . . . . CITY CUPER71NO IMPACT AREA . . . . . . OWNER SANTAlTU SINHA ADDRESS . . . . . . . . . . : 19780 DRAKE DR CITY/STATE/ZIP . . . : CUPER-INO CA, CA 95014-2469 RECEIVED FROM . . . . : GOMEZ CONSTRUCTION CONTRACTOR TBD - TO BE DETERMINED LIC # 00096 COMPANY TBD - TO BE DETERMINED ADDRESS . . . . . . . . . . CITY/STATE/ZIP . . . : , TELEPHONE . . . . . . . . FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- -----•----- ---------- ---------- ---------- 1BCBSC VALUATION 5, 200 . 00 1 . 00 0 . 00 1. 00 0 .00 1BSEISMICR VALUATION 5, 200 . 00 0 .60 0 . 00 0. 60 0 . 00 1REMRESBAT SQ FEET 1 . 00 570 . 00 0 . 00 570 . 00 0 . 00 ---- ------ ---------- ---------- ---------- TOTAL PERMIT 571 .60 0. 00 571 . 60 0 . 00 CITY OF CUPERTINO RECEIPT NUMBER: BS000010459 RECEIVED BY: PATRICIAG PAYOR: GOMEZ CONSTRUCTION TODAY'S DATE: 05/21/10 REGISTER DATE: 05/21/10 TIME: 13 :49 4 1BCBSC 10050167 $1 .00 1BSEISMICR 10050167 $ .60 1REMRESBAT 10050167 $570 . 00 BUSINESS LICENSE TAX NEW-GOMEZ CONSTRUCTION $114 . 00 ---------------- TOTAL DUE: $685 .60 CHECK $685 .60 REF NUM: #1715 "ENDERED CHANGE $685 .60 $. 00 [ C, CITY OF CUPERTINO N. ADDITION/REMODEL PEN C UT No PERMIT APPLICATION FORM APN # Date: �� 2_ � I �� , U �' Is a 2" unit being added? Yes ❑ No S If yes, please fill out the permit application for 2" unit. Building Address: Mailing Address (if different from building address): Owner's Name: Phone# -5 AkITA 0 Q (4P - Contractor: 46'f Phone Wq,_) 5-q0—&34,7 Cwl� 7YLl�C�7 l�� Fax#: ,R) 38--D Pql- Contractor License#: $p15- &L Cupertino Business License#: Contact: S J s 02) omeZ Faxo#ne# )� 3Building Permit Info: Bldg. D< Elect. ❑ Plumb. Nf Mech. ❑ Hillside ❑ Job Description: � �V e y aP14`E AC-G r,Y-Toa6 Addition-What is being added?(Be Specific): Tile -i-9-mr to04IPE-; o What is being remodeled (not including addition)? (vv f}5T6Z-- g-F"r-H 2Eilv806L' 1-t V6 r-oe- L4 V-6. Remodel Includes Re-Roof. Yes ❑ No g [f yes list number of squares AJ/f Remodel Includes Structural: Yes ❑ No 9 Do you have the pre-application planning approval? Yes ❑ No If yes, please provide a copy of your planning ap roval letter. Planners name: Square Footage: Addition: --Q)- Porch: Deck: _ Garage: Detached Attached Remodel: Kitchen Bath . Oth;r Type of Construction (Usage Class): Occupancy Type: I-A, 1-B ❑ II/III/V-A ❑ II/III B, IV-HT, V-B a] Valuation: • Please check this box if the project is a second-story addition ❑ Project Size: Express ❑ Standard ❑ Large ❑ Major❑ Please complete relevant portion of the Green Buildir..g Checklist& attach it to the application or if applicable, Green Building Points Achieved: include in plan set& the sheet index. ***For Office Use Only*** Over-the-Counter ❑ Revised 07/06/09 CITY OF CUPERTINO ADDITON/VXMODEL FEE SCHEDULE Quantity Fee ID Fee Description. Fee Group Permit Type Sq Ft DECKS 1R3SFDADD OR 1R3SFDREM 1DECKWOOD Deck (Wood)-Eacf. B (Each) 1 DECKRAIL Deck Railing-Each B (Each) GARAGES 1R3SFDADD OR DETACHED 1R3SFDREM 1 GARDTW<=1 K Wood Frame up to B 1,000 SF (each) 1 GARDTM<=1 K Masonry up to 1,000 SF B (each) 1BCONSTAXR Construction Tax Fres (new detached gar ge) PATIO'S OPEN 1R3SFDADD OR 1R3SFDREM 1PATIOWOOD Wood Frame up to 300 B SF 1 PATIOMETAL Metal Frame up to 300 B SF 1 PATIOOTHER Other Frame up to 300 SF B PATIO'S CLOSED 1R3SFDADD OR & SUN ROOMS 1R3SFDREM 1PATIOENCLW Enclosed Wood up to 300 B SF 1PATIOENCLM Enclosed Metal up to 300 B SF 1PATIOENCLO Other Enclosed Pai:io up B to 300 SF 1 COVPORCH Porch Covered-Each B (Each) REMODELS 1R3SFDREM 1REMRESKIT Kitchen Remodel tip to B (Deduct "$"for ea plan 300 SF check 1REMRESBAT Bath Remodel up to 300 B " J SF 1 REMREOTH Other Remodel up to 300 B " SF CITY OF CU PERTINO ADDITON/REMODEL FEE SCHEDULE Quantity Fee ID Fee Description Fee Group Permit Type Sq Ft 1MECPLNCK Stand Alone Mechznical M Pln Ck(hourly 1PLMPLNCK Stand Alone Plumbing P Pln Ck (hourly) / 1 BCBSC Cal Bldg Standards B ALL PERMIT TYPES Commission Fee 1 BSEISMICRE Seismic Residential B 1TRAVDOC Travel & Documentation B j 1 BUSLIC Business License B 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: 0A rl SO IMA-tf TCAVV6 PERMIT# I k-�, V v L OWNER'S NAME: S00fAJTAAte StA)4�A PHONE 44,oS5q0—&73(0 GENERAL CONTRACTOR: Gy�z— �9�7rWP�` Zig BUSINESS LICENSE# ADDRESS: g3 >��' . �,� _Ofij� M S71 CITY/ZIPCODE: A) V 12 *Our municipal code requires all businesses working in the city to have a City of Cupertino business license. NO BUILDING FINAL OR FINAL OCCUPANCY INS PECTION(S) WILL BE SCHEDULED UNTIL THE GENERAL CONTRACTOR AND ALL SUBCONTRACTORS HAV OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE. / I am not using any subcontractor . Signature Date Please check applicable subcontractors and complete the following information: V 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 A& Owner/Contractolw9nature Date