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10020021 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 21408 KRZICH PL C JNTRACTOR:ALI'S CONSTRUCTION& PERMIT NO: 10020021 R:MODELING ----'NER'S NAME: INDIRA&BABU NOTT 6111 E BROKAW RD DATE ISSUED:02/02/2010 PHONE NO:(408)898-6474 v4NER'S PHONE: 4082571708 S kN JOSE,CA 95112 ❑ LICENSED CONTRACTOR'S DECLARATION E UILDING PERMIT INFO: BLDG ELECT PLUMB License Class Lic.# MECH[_ RESIDENTIAL r— COMMERCIAL r Contractor Date JOB DESCRIPTION:ELEC PANEL UPGRADE TO 200AMP 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 Valuation:$500 performance of the work for which this permit is issued. ;;q.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 1kPN Number:36206040.00 Occupancy Type: 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 upon the above mentioned property for inspection purposes. (We)agree to save WITHIN 180 DAYS OF PERMIT ISSUANCE OR indemnify and keep harmless the City of Cupertino against liabilities,judgments, 180 DAYS 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 - Date: with all non-point source regulations per the Cupertino Municipal Code,Section Issued 9.18. S;-nature Date RE-ROOFS: All roofs shall be inspected prior to any roofing material being installed.If a roof is 13OWNER-BUILDERDECLARATION 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: Date: I,as owner of the property,or my employees with wages as their sole compensation, Signature of Applicant: 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). HAZARDOUS MATERIALS DISCLOSURE I hereby affirm under penalty of perjury one of the following three I have read the hazardous materials requirements under Chapter 6.95 of the declarations: 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 rtino Compensation,as provided for by Section 3700 of the Labor Code,for the compliance Safety Code,Sect on 25532(a)should Ithe Cupe nal to a ode, ehhandle Chapter 9.12 hazardou sthe mateHal�th& performance of the work for which this permit is issued. Additionally,should I use equipment or devices which emit hazardous air I have and will maintain Worker's Compensation Insurance,as provided for by contaminants as defined by the Bay Area Air Quality Management District I will Section 3700 of the Labor Code,for the performance of the work for which this 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 O r r authorized agent: & Date: Z� O 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 CONSTRUCTION LENDING AGENCY forthwith comply with such provisions or this permit shall be deemed revoked. 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 u- `he above mentioned property for inspection purposes.(We)agree to save i iify and keep harmless the City of Cupertino against liabilities,judgments, ARCHITECT'S DECLARATION cons,and expenses which may accrue against said City in consequence of the granting 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 Licensed Professional 9.18. " t 0- 7 Z 2_r) f O Signatu ✓ �LDate CITY OF CUPERTINO 5 ITEMS OF 5 PERM"T RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: B'-k: Lot: APN . . . . . . . . : 36206040. 00 DATE ISSUED. . . . . . . : 02/02/2010 RECEIPT #. . . . . . . . . B:3000009673 REFERENCE ID # . . . : 10020021 SITE ADDRESS . . . . . : 21408 KRZICH PL SUBDIVISION . . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . OWNER INDIRA & BABU NOTT ADDRESS 2L408 KRZICH PL CITY/STATE/ZIP . . . : C'JPERTINO CA, CA 95014-4943 RECEIVED FROM . . . . : BABU R NOTT CONTRACTOR . . . . . . . : A:�I ZAMANI LIC # 28677 COMPANY A�I' S CONSTRUCTION & REMODELIN ADDRESS 631 E BROKAW RD CITY/STATE/ZIP . . . : SAN JOSE, CA 95112 TELEPHONE ( 108) 898-6474 FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- ---------- 1BCBSC VALUATION 0 . 00 1. 00 0 . 00 1. 00 0 . 00 1BSEISMICR VALUATION 0 . 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 AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CHECK 127.50 #1742 --------------- TOTAL RECEIPT 127. 50 �S, M, CITY OF CUPERTINO CUPEI�TINO GENERAL BUILDING PERMIT APPLICATION FORM APN # t Date: Building Address • Mailing Address (if different from building address): Are Hazardous Materials being used as part of this project? Yes ❑ No HOA: Exterior work only) Yes ❑ No L4/t' es, provide letter from HOA Owner's Name: / Phone#: 20 ontractor: Phone: OCA — O • � � � =� � � .5 / Fax: Contractor License#: Cupertino Business License#: Contact: Phone: Fax: Residential Commercial ❑ Job Description: �2 Building Permit Info: Bldg ❑ Elect ©-- Plumb ❑ Mech ❑ Type of Construction(Usage Class): Occupancy Type: 1-A, 1-B ❑ II/III/V-A ❑ II/III B, IV-HT,`'-B 9--- V 1 Valuation: �7-0 O (- a j Square Footage: Project Size: Express Standard ❑ Larg,- ❑ Major ❑ Green Building: Please complete relevant portion of the Green Building/LEED Checklist& attach it to the application or if applicable, include in plan set& the sheet index. Points Achieved: For help, contact Build it Green at www.builditlyeen.orst Revised 07/14/09 CITY OF C UPERTINO SIMY GENERAL BUILDING APPLICATION CUPE(�T FEE SCl3EDULE Quantity/Sf Fee ID Fee Description Fee Permit Type Group 1GENRES or 1GENCOM 1STUCOAP Stucco Applications (up to 400 sf) B additional !;tucco application 1WINREP Replacement windows/sliding glass B door (ea 8 windows) 1WINMEWSTR New Window-structural shear B wall/masonry(includes plan ck fee) IEPERMITFEE Electrical-?ermit Fee E 1 MPERMITFEE Mechanical Permit Fee M 1PPERMITFEE Plumbing Permit Fee P IELCPLNCK Stand Alcne Electric Pln Ck(hourly) E 1 MECPLNCK Stand Alc ne Mechanical Pln Ck(hrly) M 1PLMBLNCK Stand Alone Plumbing Pln Ck(hrly) P 1 STPLNCK-(3 Hr Min Standard Plan Check(when no E/M/P) B when not over counter) hourly-st ind alone 1BCBSC Cal Bldg Standards Commission Fee B ALL PEPESRMIT TY 1BSEISMICR Seismic 3esidential B 1BSEISMICO Seismic Commercial B 1TRAVDOC Travel &Documentation B 1BUSLIC Busines; License B 5 of 5