07110040 CITY OF CUPER'�'INO
BUILDINC DIVISION ' PERMIT �������� �������� :
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PERMIT NO.
BUILDING ADDRESS:
1021 NOVEMBER DR MANA GENER.AL CONTRACTOR 07110040 .
PERMTf L�UE DATE
'NER'S NAME: ,
SHAH, DEEPA 1839 TPMPA WAY 11/08/2007
SANTI'ARY NO. CONTROL NO.
PHONE:
(408)375-4288
BUI[,DING PERMIT INFO
ARCHITECI7ENGINEF3t: gLDG ELECI' PLUMB MECH
� � 0 �
u p � LICENSED COKi'RAC1'OR'S DECLARATION TOU DCSCI7pLlOI1
V� I hcrcby afGrm tha� I am licensed unJer provisions of Chapicr 9(commcncing
�z� wi�hSection7o(xI)o[Division3ofiheBusinessandProtcssiunsCodc INSTL `I' EMPORARY POWER
�� y in full focce and e[C Q
j v� Z Licensc CI L�. � 0
±� ;, p Daic Conuactor
g � ARCHITECI'S DECLARATION
� p; -� I undcrstand my plans sha111x uxd u public rccorda
�yU
� 4. y Licensed Prufcssional
n y � OWNER-BUILDER DECLARA170N
I hcrcby a17rtn �et 1 am cxcmp� Crom ihc Conuactars Liccnsc Law Cor tt�
� p O foltowing rcason. (Sccdon 703I.5, Busincss and Profcssions Codc: Any city or couniy
K,°, � which rcqui�cs a pcimit to cnnswc4 altcr, improvc, demolish, or iepair any suucwre
y Z} prior ui i�s issuance, slso requims the applicant (ar such permit to file a signed su�emem Ft. Floor Area Valuation
< that hc is licenx d pursuan l �o � h c p ro vi s i o n s o[ t h c C o n u a c t o r' s L i c c n s c L a w ( Cha ptcr 9 S q• � 4 � �
� I �(commcncing wi�h Secdon 7000) of Division 3 of Ihc Busincsc and Profcssions Cadc) or
y�� �hat he ia exempl theteftom md ihe buis Cor ihe allcgcd exemption. My v�olation of OCCUP871C�7 Type
Section 7031.5 by azry applicant for a permi� subjecu ihe applicant to a civil penatty of 3 6 216 0()1 �� Number
not more than five 6undrcd doltars (5500).
❑ 1. u ownec of tt�e property. or my employees with wages u the'v sole compensation,
w iIId o theworkandihcstiucw�eisnocintendedorottecedtorsaie(Sa. 7 ooe.Business Required Inspections
and Professions Cade: The Conuutor's License Law docs not apply w m owner of
property who 6uilds or improves ihercun, and who das such work himselt or Uuuugh his
own emptoyces. Providcd thst such improvemen�s ue not imm�ded or o(fered for sala If,
hawever, the building or improvement is sold wilhin one yeu of completion, Ihe owner-
builder will have �he borden uf Pmving tlwt hc did not build or improvc for puryose of
sale.).
0 I, as owner of �he propeny, am exclusively conlracting wiW licenud rnnvactors w
conswct �he pmjea (Sec. 7044. Business and ProCessions Code:) 7he Contracwr's Li-
ccnse Law docs no� apply W an ownu of propeny who builds or improves �he�eoo. and .
who conuacls for such projects with a conlracar(s) liansed purswnt w �he Convactoc's
License Law.
"1 I am uempt under Sec. , B dc P C for �his rcsson
, Date
WORKF3t'S COMPENSA'I70N DECLARA'I70N
I hereby �rm under penaity of peryury one o( the [allowioB dec�uatiuns:
❑ 1 hs+e and will mainuin a Cenifiate of Consent to xlf-insure for Workcr's Compen-
sation, ss provided for by Section 3700 of the Labor Code, for �he performancc of the
work for whieh this permit is issucd.
❑ I havc and will maintain Workcr's CompensaUon Insurana. as required by Section .
3700 of the Labor Code. Car the pedormance of the work for which this pe�mit is issued
My Worke�s Compensation lnsurancc artier and Poliry numbcr are:
Cartier., �� Poliry No.:�� � � � �
� C�ER77 CA7'E OF EXIINP'1'ION FROM WORKERS' .
' COMPENSA7TON INSURANCE
(This section necd irot bc eompletcd if the pecmit is for onc hundred dallus (S 100)
or Icss.)
1 ceniti� thut in ihc perfortnancc of t6c work fw which �his pertni� is istucd. l shall not
employ any pecson in any manner so az W bernme subject to the Workers' Compensation
Laws of Califomia. Da�c
Applican�
NOTICE TO APPLICAM: If, aficr malcing �his Ccrtificam of ExempGon, you should
bccome subjcct w �hc Worlcer's CompensaUon p�ovisions of iAe Labor Codc, you musl
� O foMwilh comply with such provisions or this permil sha116c dccmcd mroked.
Z "" CONSTRUCTION LENDING AGENCY
F r .�•. I hcropy a[firtn Uut thcre is a co2suuctinn ►cnding agcncy for �hc perCortnance o! �
�� �hc work fur which this permit is issued (Scc. 3097� Civ. CJ .
GLl Q L.endcr's Namc
� � L.cnder's Address
I certity U�at 1 have read tltis spplieation snd s�atc that thc abovc informatiun is
w� cortcci. ! agree W comply wi�h all ciry and county oNinances and sute Iaws relaung w
0 U building consuucaon, and hcieby authoriae rcprcscnuuvcs of Wis cily w cmer upon thc
� W above-mcntioned piupertY for inspec�ion purpatea
a (Wc) agree w save, indcmnity and keep harmless �he Cily of Cupertino agaimt �/
�� liabi►iuu, judgmcnts, costs and expcnses which may in any way accruc against seid CitY /�' %-- `,� "
V`� in conseq C thc g ting oC this permi� Date f � ��
►" APPLI U DE NDS AND WILL COM Y WITH ALL NON-POINT Issued b� :
SOUR R LA
Re-roof: /�_.-�
s��^�� � °se T of Roof
OUS MATERIALS DISCLOSURE YP
wll Ihc applinnt or fu�wc building accupant storc or handle ha•rardous malcriil
kfincd by �he Cupertino Municipal Codc. Chap�cr 9.12. �nd the Health and Safcty
,�, Scction 25532(a)? All roof,� shall be inspected prior to any roofing material being installed.
� � If a roof is installed without first obtaining an inspection, I agree to remove
Wilt thc applicant or future building accupant ux equipmcnt or �viccs which
emit ha air coniaminamt u dcfincd by the Bay Area Air Quality ManagcmcM all new ; naterials for inspection.
Dis�rict? ,,,�
�Ycs Gry�
1 have the hva�d ma�crials requircmcn�s undcr Chapicr 6.95 of U�e Glifor-
nia Hcal ct Cadc 25505, 25533 and 25534.1 w d Ihat iC ihe buildin`
docs no cu ha a n 4� it is my responsiAiliry lo fy �he occupant nf Ihe
rcyuire ems h hm priormissuar�ccofaC fic ro«�P��r. SignatureofApplicant � Date
All roof coverings to be Class "B" or better
Own —_ _ Datc '
CITY OF CUPERTINO
2 ITEMS OF 2 pERMI" RECEIPT OPERATOR: patg
COPY # : 1
Sec: Twp: Rng: Sub: Bl.c: Lot:
APN ......... 36:?16001.00
DATE ISSUED.......: 11/08/2007
RECEIPT #... ......: BS)00003193
REFERENCE ID # ...: 07110040
SITE ADDRESS .....: 10�1 NOVEMBER DR
SUBDIVISION .......
CITY .............. CUPERTINO
IMPACT AREA .......
OWNER ............. SHAH, DEEPA
ADDRESS ..........: 1221 CRESCENT TERRACE
CITY/STATE/ZIP ...: SUNNYVALE, CA 94087
RECEIVED FROM ....: CARLOS ORELLANA
CONTR.ACTOR .......: CARLOS ORELLANA LIC # 27468
COMPANY ..........: MANA GENERAL CONTRACTOR
ADDRESS ..........: 1839 TAMPA WAY
CITY/STATE/ZIP ...: SAN JOSE, CA 95122
TELEPHONE ........: (408)375
FEE ID UNIT QUANTITY AMOiTNT PD-TO-DT THIS REC NEW BAL
------------- ---------- ---------- --------
BTEMP FLAT RATE 1.00 62.10 0.00 62.10 0.00
EPERMITFEE FLAT RATE 1.00 40.79 0.00 40.79 0.00
---------- ---------- ---------- ----------
TOTAL PERMIT : 102.89 0.00 102.89 0.00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- -----------------
CREDIT CARD 102.89 VISA
---------------
TOTAL RECEIPT : 102.89
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ----------------------------- -------- ------
103 UFER 304 ROUGH ELECTRICAL
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�UPfI�TiNO PERMIT APPLICATION FORIVI
APN # / Date:
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Building Address:
t n� r�o �� b��- D�r
Owner's Name: Phone #:
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' Contractor: Phone: License #:
v1� ►-�.r�- � �� ��c.�--a� � � �3 Z`� 1 °
C ntact: Phone: � Cupertino Business License #:
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Building Peimit Info:
Elect
Job Description:
i I � o� T-� �^'� r�_ .� �. -
Residential � Comm rcial ❑
Cost of Project: J ,
- 00
Qty. if
A licable Fee ID Fee Descri tion Fee Group
BTEMP T�m orary Power ELECTRICAL
j EPERMITFEE Elect. Permit Issuance ELECTRICAL
BUSLIC E usiness License BUILDING
Community Development
��`~, ' 10300 Torre Avenue
�,; ,=�, Cupertino CA 95014
.,�, .
Telephone (408) 777-3228
�ClTY OF Fax (408) 777-3333
CUPERTINO
Buildin De artment
OB ADDRESS: PERMIT #
J C��-- \�° v�`^^ �`z'`� � Y' �7 ( � U�'`� U
OWNER'S NAME: ' �-� �� �.pA� PHONE # L�o�" 3"�5 Z�
GENERAL CONTRACTOR: r�l� vlr-t C,�u. o FAX #
� �` (1 0�' o
I am not using any subcontractors:
_ _ � ��. Date
Please check a licable subcontractors and com lete the followin information:
SUBCONTRACTOR BUSIIJESS 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
T'
�� C 1 C�� o
�-Earttra or Signafixre Date