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09090170I CITY OF CUPERTINO BUILDING PERMIT I IBUILDING ADDRESS: 10198 RICHWOOD DR I CON TRUCTOOR: TV GENERAL I PERMIT NO: 09090170 I (""NER'S NAME: SUSHMA SHIRISH 4,- NER'S PHONE: 4088885227 ❑ LICENSED CONTRACTOR'S DECLARATION License Class v n //Lic. # S 7 / 3 2- Contractor a c hl) I `) Date -714-9- 1 7 431 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. % S;-^atureDate :> 7/ ❑ 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 to building construction, and hereby authorize representatives of this city to enter the above mentioned property for inspection purposes. (We) agree to save .rnify 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. Signature Date 1510 RHINECLIFF WAY SAN JOSE, CA 95126 DATE ISSUED: 09/22/2009 PHONE NO: (408)858-0108 BUILDING PERMIT INFO: BLDG f— ELECT r- PLUMB f— MECH f— RESIDENTIAL f— COMMERCIAL f— JOB DESCRIPTION: ELECTRICAL PANEL UPGRADE TO 200AMP Sq. Ft Floor Area: I Valuation: $1500 APN Number: 36908029.00 1 Occupancy Type: PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTION. Issuedb �. '"� Date: t_c-% 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. I 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, 25533, and 25534. Owner or authorized agent: l' � C 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 Address ARCHITECT'S DECLARATION I understand my plans shall be used as public records. Licensed Professional 6 ITEMS OF 6 CITY OF CUPERTINO PERMIT RECEIPT Sec: Twp: Rng: Sub: Blk: Lot: APN ........: 36908029.00 DATE ISSUED.......: 09/22/2009 RECEIPT #......... BS000008742 REFERENCE ID # 09090170 SITE ADDRESS 10198 RICHWOOD DR SUBDIVISION ...... CITY CUPERTINO IMPACT AREA ...... OPERATOR: patg COPY # : 1 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CHECK 241.50 #646 --------------- TOTAL RECEIPT 241.50 OWNER ............: SUSHMA SHIRISH ADDRESS . 10198 RICHWOOD DR CITY/STATE/ZIP ...: CUPERTINO CA, 95014-3314 RECEIVED FROM ....: TV GENERAL CONT COR CONTRACTOR .......: THANH DINH LIC # 27960 COMPANY ..........: TV GENERAL CONSTRUCTION ADDRESS ..........: 1510 RHINECLIFF WAY CITY/STATE/ZIP ...: SAN JOSE, CA 95126 TELEPHONE ........: (408)858-0108 FEE ID UNIT QUANTITY AMOUNT PD -TO -DT ---------- THIS REC NEW BAL ---------- 1BCBSC --------------------------------- VALUATION 1,500.00 1.00 0.00 1.00 0.50 0.00 0.00 1BSEISMICR VALUATION 1,500.00 0.50 0.00 0.00 114.00 0.00 1BUSLIC FLAT RATE 1.00 114.00 42.00 0.00 42.00 0.00 1EPERMITFE FLAT RATE 1.00 1.00 42.00 0.00 42.00 0.00 1ERT<200 UNITS 1.00 42.00 0.00 1TRAVDOC -----42_00 FLAT RATE ------ --- ------0_00 ---------- 241.50 0.00 241.50 0.00 TOTAL PERMIT METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CHECK 241.50 #646 --------------- TOTAL RECEIPT 241.50 09 Oct o lry, 4 -10 CITY OF CUPERTINO CUPEkTINO GENERAL BUILDING PERMIT APPLICATION FORM APN # r Date: Building Address: >� f� W L,�x� or Mailing Address (if different from building address): Are Hazardous Materials being used as part of this project? Yes U No M HOA: Exterior work on- Yes ❑ No [J If yes, provide letter from HOA Owner's Name: // / Phone #: Contractor,_ Phone: Ll ��er1�i�� C�/''czC fi'� Fax: Contractor License 95 7 3,-Z-. Cupertino Business License #: Contact: Phone: nuc d Fax: Residential Commercial Job Description: P Eli?�n� �-��{�_� tl Building Permit Info: Bldg ❑ Elect ( Plumb ❑ Mech ❑ Type of Construction (Usage Class): Occupancy Type: 1-A, 1-B F-1II/III/V-A [III/III B, IV -HT, V -B Q —,-3 Valuation: �iSrJ Square Footage: Project Size: Express Manta or Green Building: Please complete relevant portion of the Green Building/hhhu %-necxust m MUWU IL to the application or if applicable, include in plan set & the sheet index. Points Achieved: C For help, contact Build it Green at www.buildit reen.or Revised 07/14/09 CNI's? CITY OF CUPERTINO nof GENERAL BUILDING APPLICATION CUPEf�TINO FEE SCHEDULE Quantity/Sf Fee ID Fee Description Fee Group Permit Type 1GENRES or 1GENCOM 1STUCOAP Stucco Applications (up to 400 sf additional stucco application B 1 WINREP Replacement windows/sliding glass door (ea 8 windows) B 1WINMEWSTR New Window -structural shear wall/masonry (includes plan ck fee) B IEPERMITFEE Electrical Permit Fee E 1 MPERMITFEE Mechanical Permit Fee M 1PPERMITFEE Plumbing Permit Fee P IELCPLNCK Stand Alone Electric Pln Ck (hourly) E 1MECPLNCK 1PLMBLNCK Stand Alone Mechanical Pln Ck (hrly) M Stand Alone Plumbing Pln Ck (hrly) P 1 STPLNCK-(3 Hr Min when not over counter)__hourly-stand r 1BCBSC 1BSEISMICR 1BSEISMIC0 1TRAVD0C 1BUSLIC Ze)o Standard Plan Check (when no E/M/P) alone Cal Bldg Standards Commission Fee Seismic Residential Seismic Commercial Travel & Documentation Business License 5of5 B B B B B B ALL PERMIT TYPES CITY OF XPEkTINO Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone (408) 777-3228 Fax (408) 777-3333 Building Department JOB ADDRESS: PERMIT # 7 v a ii16.aaii....a..i...v�.,.....,.....�..._ SUBCONTRACTOR .....--- ---- BUSINESS NAME OWNER'S NAME: SCIS/YID S vi i� PHONE GENERAL CONTRACTOR: i= Chi tee_ '>" FAX # I am not using any subcontractors: a, -,� ignature Date rn___ ,7 ..L ,..1;,. 1.10 „1-v-r.,,+rar-+r►rc anr� rmmnlPte the following information: 1 1CdSC l.1LCl.11 a ii16.aaii....a..i...v�.,.....,.....�..._ SUBCONTRACTOR .....--- ---- BUSINESS NAME BUSINESS LICENSE # Cabinets & Millwork Cement Finishing Electrical Excavation Fencing Flooring: Carpeting Linoleum / Wood Glass / Glazing Heating Insulation Landscaping Lathing Masonry Ornamental Sheet Metal Painting / Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile Owner/Contractor Signature Date