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10040174I I I CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 20364 GILLICK WAY 'NER'S NAME: NIRMALENDU & SAGORIKA DAS OWNER'S PHONE: 4088874761 ❑ LICENSED CONTRACTOR'S DECLARATION License Class Lic. # Contractor Date 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. 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 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 to building construction, and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We) agree to save 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 with all non -point source regulations per the Cupertino Municipal Code, Section 9.18. Date OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: 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 construct the project (Sec.7044, Business & Professions Code). I hereby affirm under penalty of perjury one of the following three 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 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 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 forthwith comply with such provisions or this permit shall be deemed revoked. 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 * building construction, and hereby authorize representatives of this city to enter i the above mentioned property for inspection purposes. (We) agree to save i..,,emnify and keep harmless the City of Cupertino against liabilities, judgments, costs, and expense which may accrue against said City in consequence of the granting of this pNit. Additionally, the applicant understands and will comply with all non -point source regulatiprr9.per the Cupertino Municipal Code, Section 9.18. < \` Signature `� '-- '� Date CONTRACTOR: MANA GENERAL CONTRACTOR 1839 TAMPA WAY SAN JOSE, CA 95122 JOB DESCRIPTION: RESIDENTIAL TEMP POWER PERMIT NO: 10040174 DATE ISSUED: 04/30/2010 PHONE NO: (408)375-4288 COMMERCIAL Sq. Ft Floor Area: I Valuation: $1000 APN Number: 36936009.00 1 Occupancy Type: PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTION. Issued by: Date: RE -ROOFS: 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 inspection. Signature of Applicant: Date: ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER HAZARDOUS MATERIALS DISCLOSURE I have read the hazardous materials requirements under Chapter 6.95 of the California Health & Safety Code, Sections 25505, 25533, and 25534. 1 will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Section 25532(a) should I store or handle hazardous material. Additionally, should I use equipment or devices which emit hazardous air 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 Health & Safety Code, Sections 25505, 2553 nd 25534. Owner or authorized agentl i,' . Date: CONSTRUCTION LENDING AGENCY 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.) Lender's Name Lender's ARCHITECT'S DECLARATION I understand my plans shall be used as public records. Licensed Professional 5 ITEMS OF 5 CITY OF CUPERTINO PERMIT RECEIPT Sec: Twp: Rng: Sub: Blk: Lot: APN ........: 36936009.00 DATE ISSUED.......: 04/30/2010 RECEIPT #......... BS000010289 REFERENCE ID # ...: 10040174 SITE ADDRESS 20364 GILLICK WAY SUBDIVISION ...... CITY CUPERTINO IMPACT AREA ...... OPERATOR: SylviaM COPY # : 1 OWNER NIRMALENDU & SAGORIKA DAS ADDRESS ..........: 20364 GILLICK WAY CITY/STATE/ZIP ...: CUPERTINO CA, CA 95014-4413 RECEIVED FROM NIRMALENDU DAS CONTRACTOR .......: CARLOS ORELLANA LIC # 27468 COMPANY MANA GENERAL CONTRACTOR ADDRESS 1839 TAMPA WAY CITY/STATE/ZIP ...: SAN JOSE, CA 95122 TELEPHONE ........: (408)375-4288 FEE ID UNIT QUANTITY AMOUNT PD -TO -DT ------- THIS REC NEW BAL ---------- 1BCBSC ------------- VALUATION ---------- 1,000.00 ---------- 1.00 0.00 1.00 0.00 1BSEISMICR VALUATION 1,000.00 0.50 0.00 0.50 0.00 1EPERMITFE FLAT RATE 1.00 42.00 0.00 42.00 0.00 1ERT<200 UNITS 1.00 42.00 0.00 42.00 0.00 1TRAVDOC FLAT RATE 1.00 42.00 0.00 ---------- 42.00 ---------- 0.00 ---------- TOTAL PERMIT ---------- 127.50 0.00 127.50 0.00 METHOD OF PAYMENT ----------------- CREDIT CARD TOTAL RECEIPT : AMOUNT --------------- 127.50 --------------- 127.50 REFERENCE NUMBER -------------------- AX VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ----- 402 TEMPORARY POWER CITY OF CUPERTINO " TEMP POWER CUPC11EI�TINO PERMIT APPLICATION FORM APN # Date: Building Address: �' �� `0-� L Owner's Name:�,� , Phone#: r Contractor: WU�� ,, e ,v,, ,y/, I ( Phone #:,,-f C Contact: 1 cti� c. Contractor License #: Kl I 0 9 Fax #: Phone #: Cupertino Business License #: 9, -} zi { W Job Description: Residential 14 Commercial LJ Valuation (cost of project): g 0-t-0, CJ Type of Constructio : N/A Fee ID IERT>IK Fee Description Fee Group Permit Type Quantity Res. Temp Power >1K Amps E 1REAP14 IERT<200 Res. Temp Power <200 Amps E Res. Temp Power 200-1 K Amps E 1 ERT2001 K IEPERMITFE Electric Permit Issuance E Electric Plan Check E 1 ELCPLNCK Cal Bldg Standards Commission Fee B ALL PERMIT _ TYPES 1BCBSC Seismic Residential B 1BSEISMICR Travel & Documentation Fee B % 1TRAVDOC Revised 01 /07/09