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09100176 (2) CITY OF CUPERTINO BUILDING PERMIT BUILDING,AISDRESS: 10375 CALVERT DRIVE CONTRACTOR:TBD-TO BE DETERMINED PERMIT NO:09100176 OWNER'S NAME: NASHEETA MOHSIN DATE ISSUED: 10/26/2009 'ER'S PHONE: 4086916696 PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ELECT f— PLUMB License Class Lic.# MECH RESIDENTIAL COMMERCIAL Contractor Date I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:SERVICE UPGRADE TO 125 AMP (commencing with Section 7000)of Division 3 of the Business&Professions Code and that my license is in full force and effect. 1 hereby affirm under penalty of perjury one of the following two declarations: 1 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 Sq.Ft Floor Area: Valuation:$1400 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 APN Number:37517026.00 Occupancy Type: permit is issued. APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED correct.I agree to comply with all city and county ordinances and state laws relating WITHIN 180 DAYS OF PERMIT ISSUANCE OR to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We)agree to save 180 DAYS FROM LAST CALLED INSPECTION. 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 Issue y: with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. Signature Date RE-ROOFS: All roofs shall be inspected prior to any roofing material being installed.If a roof is OWNER-BUILDER DECLARATION installed without first obtaining an inspection,I agree to remove all new materials for inspection. I hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: Signature of Applicant: Date: 1,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) 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: California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain I have and will maintain a Certificate of Consent to self-insure for Worker's compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health& Compensation,as provided for by Section 3700 of the Labor Code,for the Safety Code,Section 25532(a)should 1 store or handle hazardous material. 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 maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the Section 3700 of the Labor Code,for the performance of the work for which this Health&Safety Code,Sections 25505,25533,and 25534. permit is issued. I certify that in the performance of the work for which this permit is issued,I shall Ownf�orff_tu�t ��`ed/agent: lU l not employ any person in any manner so as to become subject to the Worker's Iv` \ �C/\V`y Date: 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 for which this permit is issued(Sec.3097,Civ C.) APPLICANT CERTIFICATION Lender's Name 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 Lender's Address to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes.(We)agree to save ARCHITECT'S DECLARATION inify and keep harmless the City of Cupertino against liabilities,judgments, and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records. granting of this permit.Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code,Section Licensed Professional 9.18. Signature ` Date CITY OF CUPERTINO 5 ITEMS OF 5 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN . . . . . . . . : 37517026 . 00 DATE ISSUED. . . . . . . : 10/26/2009 RECEIPT #. . . . . . . . . : BS000009041 REFERENCE ID # . . . : 09100176 SITE ADDRESS . . . . . : 10375 CALVERT DRIVE SUBDIVISION . . . . . . CITY . . . . . . . . . . . . . . CUPERTINO IMPACT AREA . . . . . . OWNER . . . . . . . . . . . . : NASHEETA MOHSIN ADDRESS . . . . . . . . . . : 10375 CALVERT DRIVE CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM . . . . : CARLOS MORALES GENO 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 1, 400. 00 1 . 00 0 . 00 1. 00 0 . 00 1BSEISMICR VALUATION 1, 400. 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 ----------------- --------------- -------------------- CREDIT CARD 127 .50 MC --------------- TOTAL RECEIPT 127 .50 !i!ilil��...FFFFCCCC CITY OF CUPERTINO CUPEf�TINO GENERAL BUILDING PERMIT APPLICATION FORM -'/ _ —7 APN# Date:b� Building Address: .l � C�i_ Mailing Address (if different from building address): Are Hazardous Materials being used as part of this project? Yes EJ No HOA: Exterior work only) Yes ❑ No �f es, provide letter from HOA Owner's Name: Phone#: S' NC� Contractor: Phone: f� Fax: Contractor License#: Cupertino Business License#: Contact: Phone: N& *JGC t; M61+&14 Fax: Residential Commercial Fj Job Description: 5E`R�li C \,Jp6LA<01 1% 1'l,� (�►v!{� Building Permit Info: Bldg ❑ Elect'\Z Plumb ❑ Mech ❑ Type of Construction (Usage Cl ss): Occupancy Type: 1-A, 1-B ❑ II/III/V-A ❑ II/III B, IV-HT, V-B \`- 3 Valuation: Square Footage: Project Size: Express ❑`Standard ❑ Large ❑ 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: ctj For help, contact Build it Green at www.buflditgreen.org Revised 07/14/09 CITY OF CUPERTINO stv.�_ OF GENERAL BUILDING APPLICATION CUPEI�TINO FEE SCHEDULE Quantity/Sf Fee ID Fee Description Fee Permit Type Group 1GENRES or 1GENCOM 1STUCOAP Stucco Applications (up to 400 sf) B additional stucco application 1 WINREP Replacement windows/sliding glass B door (ea 8 windows) 1 WINMEWSTR New Window-structural shear B wall/masonry(includes plan ck fee) 1 EPERMITFEE Electrical Permit Fee E 1 MPERMITFEE Mechanical Permit Fee M 1 PPERMITFEE Plumbing Permit Fee P 1 ELCPLNCK Stand Alone Electric Pln Ck(hourly) E 1 MECPLNCK Stand Alone Mechanical Pln Ck(hrly) M 1PLMBLNCK Stand Alone Plumbing Pln Ck(hrly) P 1 STPLNCK-(3 Hr Min Standard Plan Check (when no EMP) B when not over counter) hourly-stand alone 1BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT TYPES 1BSEISMICR Seismic Residential B 1BSEISMICO Seismic Commercial B 1 TRAVDOC Travel & Documentation B 1 BUSLIC Business License B ( 5 of 5 M.1n oor Air Quality and Finishes 1.Use Low/No-VOC Paint 1 IA(JHealth pts y--yes D 2.Use Low VOC,Water-Based Wood Finishes 2 IAQ/Health pts y=yes 7 . . 0 3.Use Low/h0o VOC Adhesives 3 IAQ/Health pts y=yes 0 4.Use Salvaged Materials for Interior Finishes 3 Resource pts y--yes D 5.Use Engineered Sheet Goods with no added Urea Formaldehyde 61AQ/Health pts y--yes D 6.Use Exterior Grade Plywood for Interior Uses 1 IAQ/Health pts Ayes D 7.Seal ail ihiboard or MDF---, 4 IAQ/Heal h. pts= es _ D_ B.Use FSC Certified Materials for Interior Finish 4 Resource pts y=yes D 9.Use Finger-Jointed or Recycled-Content Trim 1 Resource pts y=yes D 10.Install Whole House Vacuum System 3[AD/Health pts y--yes 0 t 1 1 N.Flooring 1.Select FSC Certified Wood Flooring B Resource pts y--yes 0 2.Use Rapidly Benenwahie Flooring Materials 4 Resource pts y=yes D 3.Use Recycled Content Ceramic Tiles 4 Resource pts y=yes 0 4.Install Natural Linoleum in Place of Vinyl 5 IAQ/Health pts Ayes D 5.Use Exposed Concrete as Finished Floor 4 Resource pts y=yes D 6.Install Recycled Content Carpet with Low VOCs 4 Resource pts y=yes D 1 1 1 Total Points Available: 1 1401 1301 57 Total Points Project Received: 61— 01 01 01 G:data/progs/greenbuildingguidelines(ramodaersfgreenpointsfinal2I?-Aprotalad.zls Community Development * 10300 Torre Avenue r{� Cupertino CA 95014 Telephone(408)777-3228 CITY OF Fax(408)777-3333 UPE�TINO Kc '?-T cwt, D�- cvP-EiiR6J6 cA Building Department JOB ADDRESS: �a �7s CZA""-� T>(- PERMIT# OWNER'S NAME: NPzS)tM1 06N PHONE # GENERAL CONTRACTOR: '"B FAX # I am not using any subcontractors: Signature Date Please check applicable subcontractors and complete the following information: 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