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10040124 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 1699 S DE ANZA BLVD CONTRACTOR:TBD-TO BE DETERMINED PERMIT NO: 10040124 DATE ISSUED:04/20/2010 OWNER'S NAME: ATAM SANDHU PHONE NO: NER'S PHONE: 4084063158 ❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class Lic.# MECH F RESIDENTIAL r— COMMERCIAL Contractor Date JOB DESCRIPTION:ADD 1 SINK&TIE INTO EXISTING FLOOR SINK DRAIN I hereby affirm that I am licensed under the provisions of Chapter 9 (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:$100 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 anc Type:Occu APN Number:36610120.01 P Y permit is issued. 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 WITHIN 180 DAYS OF PERMIT ISSUANCE OR upon the above mentioned property for inspection purposes. (We)agree to save indemnify and keep harmless the City of Cupertino against liabilities,judgments, 180 DYS FROM LAST 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 source regulations per the Cupertino Municipal Code,Section Issued by: /v Date: 9.18. Signature Date 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) ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER 1,as owner of the property,am exclusively contracting with licensed contractors to 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 maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the permit is issued. Health&Safety Code,Sections 25505,25533,and 25534. 1 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 or t erid ag wf.7 Dater Compensation laws of California. If,after making this certificate of exemption,I / I become subject to the Worker's Compensation provisions of the Labor Code,I must �r 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 'pmnify and keep harmless the City of Cupertino against liabilities,judgments, ARCHITECT'S DECLARATION and expenses which may accrue against said City in consequence of the g,anting of this permit.Additionally,the applicant understands and will comply I understand my plans shall be used as public records. with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. Licensed Professional Signature Date --_7D >/© CITY OF CUPERTINO ADDITION/REMODEL CUPEi�T1NO PERMIT APPLICATION FORM APN # Date: Is a 2" unit being added? Yes ❑ No ❑ If yes, please fill out the permit application for 2" unit. Building Address: �/� ` 0111 Mailing Address (if different from building address). Owner's Name: Phone# Contractor: Phone#: Fax #: Contractor License#: Cupertino Business License#: Phone#: Contact: T�7 Fax#: Building Permit Info: Bldg. El Elect. ❑ Plumb. Mech. ❑ Hillside ❑ Job Description: ���" , a r0 Addition-What is being added?(Be Specific): ,` rx) What is being remodeled(not including addition)? Remodel Includes Re-Roof: Yes ❑ No ❑ If yes list number of squares Remodel Includes Structural: Yes ❑ No ❑ Do you have the pre-application planning approval? Yes K No ❑ If yes, please provide a copy of your planning approval letter. Planners name: Square Footage: Addition: 578 Porch: Deck: Garage: Detached Attached Remodel: Kitchen Bath Other Type of Construction (Usage Class): Occupancy Type: 1-A, 1-13 ❑ II/III/V-A ❑ II/III B, IV-HT, V-B'S W1 Valuation: Please check this box if the project is a f �� second-story addition ❑ Project Size: Express ❑ Standard ❑ Lar e ❑ Major❑ Please complete relevant portion of the Green Building Checklist& attach it to the application or if applicable, Green Building Points Achieved: include in plan set& the sheet index. ***For Office Use Only*** Revised 07/06/09 Over-the-Counter ❑ CITY OF CUPERTINO ADDITON/REMODEL FEE SCHEDULE Quantity Fee ID Fee Description Fee Group Permit Type Sq Ft 1 MECPLNCK Stand Alone Mechanical M Pln Ck (hourly 1PLMPLNCK Stand Alone Plumbing P Pln Ck (hourly) 1 1BCBSC Cal Bldg Standards B ALL PERMIT TYPES Commission Fee 1BSEISMICRE Seismic Residential B 1TRAVDOC Travel &Documentation B 1BUSLIC Business License B CITY OF CUPERTINO 4 ITEMS OF 4 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN 36610120 . 01 DATE ISSUED. . . . . . . : 04/20/2010 RECEIPT #. . . . . . . . . BS000010223 REFERENCE ID # 10040124 SITE ADDRESS 1699 S DE ANZA BLVD SUBDIVISION . . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . OWNER ATAM SANDHU ADDRESS 1699 S DE ANZA BLVD CITY/STATE/ZIP CUPERTINO, CA 95014 RECEIVED FROM . . . . : VIKHAR INC 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 100 . 00 1 . 00 0 . 00 1 . 00 0 . 00 1BSEISMICR VALUATION 100 . 00 0 . 50 0 . 00 0 . 50 0 . 00 1PPERMITFE FLAT RATE 1 . 00 42 . 00 0 .00 42 . 00 0 . 00 1TRAVDOC FLAT RATE 1 . 00 42 . 00 0 . 00 - --- - - - --0_00 -- -------- ---------- TOTAL PERMIT 85 .50 0 .00 85 . 50 0 . 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- ----------- CHECK 85 .50 #2091 --------------- TOTAL RECEIPT 85 . 50