14030041 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 21860 ALCAZAR AVE I CONTRACTOR: lviiC7RIC PERMIT NO: 14030041
OWNER'S NAME: RAJRUPA GHOSH DATE ISSUED:03/06/2014
OWNER'S PHONE: 4085960291 PHONE NO:
,ig- LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL E] COMMERCIAL
1,7 �j,��yy �2 n INSTALL(N)50 AMP BREAKER FOR NEMA 14-50 PLUG IN
License Class Lie.# fO. GARAGE FOR EV CHARGING. (N)DEDICATED CIRCUIT
` s IN
Contractor /- Date (E)SUB PANEL
I hereby affirm that I am licensed u der the provisions of Chapter 9
(commencing with Section 7000) f ivision 3 of the Business&Professions
Code and that my license is in full orce 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. Sq.Ft Floor Area: Valuation:$950
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:35714036.00 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 C ED 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 Issued
r u // r� Date: (�
t
with all non-point source lations per the Cupertino Municipal Code,Section o/
9 18.
4�E-ROOFS:
Signature Date All roofs shall be inspecte nor to any roofing material being installed.If a roof is
installed without first obtaining an inspection,I agree to remove all new materials for
J� inspection.
❑ OWNER-BUILDER DE46RATION
jj�J Signature of Applicant: Date:
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
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)
I,as owner of the property,am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE
construct the project(Sec.7044,Business&Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the
California Health&Safety Code,Sections 25505,25533,and 25534. I will
I hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
declarations: Health&Safety Code,Section 25532(a)should I store or handle hazardous
I have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally,should I use equipment or devices which emit hazardous
Compensation,as provided for by Section 3700 of the Labor Code,for the air contaminants as defined by the Bay Area Air Quality Management District I
performance of the work for which this permit is issued. will maintain compliance with the Cupe unicipal Code,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sect' ,25P3,and 25534.
Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued. Owner or authorized agent: / /�� _. Date: #
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 CONSTRUCTION LEND G GENCY
become subject to the Worker's Compensation provisions of the Labor Code,I must I hereby affirm that there is a construction lending agency for the performance of
forthwith comply with such provisions or this permit shall be deemed revoked. work's for which this permit is issued(Sec.3097,Civ C)
Lender's Name
APPLICANT CERTIFICATION Lender's Address
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 ARCHITECT'S DECLARATION
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,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
GENERAL PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION O MEP
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 \
cupsATINO (408)777-3228•FAX(408)777-3333•building aC ..cunertino.ora J(O MISC
❑PLUMBIIAG ❑MECHANICAL ELECTRICAL ❑MISCELLAATEOUS
PROJECT ADDRESS AVe I APN# r Q 3
OWNZERNAME
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STREET ADDRESS CITY,STATE,ZIP..
CONTACT NAME . PHONE NLAII //
/1 E-
t2 I � le
STREET ADDRESS CITY,STATE,ZIP FAX
-5;-OWNER ❑ OV7,TER-BUILDER ❑ OVIAM AGENT
7 ❑ C0NIRACTOR ❑CONIR ACTOR A�GGFNr ❑ ARCHITECT ❑ENGD'TER ❑ DF\'ELOPER ❑TENANT
CONTRACTOR NAME t L! LICI ISE N bIBER q1j V I I LICENSE TYPE6.,e ff ' BUS.LIC#
COMPANY NAME E-MAIL r FAX
lydl,t
STREET ADDRESS CTTY,STATE,ZIP �II PHONE
re
ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC#
COMPANY NAME I E-MAIL FAX
STREET ADDRESS I CITY,STATE,ZIP PHONE
USE OF ❑SFD o,DUPLEX ❑ MULTI-FAMILY PROJECT IN WI ULAND ❑ YES PROJECT IN ❑YES IS THE BLDG AN ❑ YES
BUII..DING: ❑COMt,4ERCIAL ( URBAN INTERFACE AREA ❑ NO I FLOOD ZONE ❑NO EICHLER HOME? ❑ NO
DESCRIPTION OF WORK
TOTAL VALUATION/// /l e_ _
-
By my signature below,I certify to each of the fol g: I am the property owner or authorized agent to act on the property owner's behalf. I have read this
application and the information I have p W�TALINFO• . I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating to Id' . I authorize representativ of Cupertino to enter the ab ve-iddentifie�/�roperty for inspection purposes.
Signature of ApplicanUAgent: Date: �I SUPPLEM�IE �O REQUIRED -� ti
s _OFFSGE USElaIsY a
ffiog WOO HE CO T
c—
MEPMiSCXPp_2011.doc revised 06/21/11
CITY OF CUPERTINO
FEE ESTIMATOR—BUILDING DIVISION
91 ADDRESS: 21860 ALCAZAR AVE DATE: 03/0612014 REVIEWED BY: MELISSA
APN: 35714 036 BP#: "VALUATION: 1$950 1
*PERMIT TYPE: Electrical Permit I PLAN CHECK TYPE: Alteration/Addition/ Repair
PRIMARY SFD or Duplex PENTAMATION 1REAP
USE: PERMIT TYPE:
WORK INSTALL (N) 50 AMP BREAKER FOR NEMA 14-50 PLUG IN GARAGE FOR EV CHARGING. (N)
SCOPE I DEDICATED CIRCUIT IN (E) SUB PANEL
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Special Circuits 1BREMMISC 1 # $139
Recep/Switch/Outlets 1 BREMRECEP 1 # $47
TOTALS: I I $186.00
t't:;r b. Plu,a Owc-6 1 r Elec.Plan Check 10.0 I hrs $0.00
P rrurt Fr>e:
I Pura,•";1"ec. Elec.Permit Fee: IEPERMIT
01 e>r Alum 1,Insp. � I Other Elec.Insp. 0.0 hrs 1 $47.00
NOTE: This estimate does not include fees due to other Departments(i.e.Planning,Public Works,Fire,Sanitary Sewer District,School
District,etc.). These fees are based on the preliminary information available and are only an estimate. Contact the Dept for addn7 info.
FEE ITEMS (Fee Resolution 11-053 Eff.' 711113) FEE QTY/FEE I MISC ITEMS
PME Plan Check: $0.00
PME Unit Fee: $186.00
PME Permit Fee: $47.00
Administrative Fee: IADMIN $44.00
+Work Without Permit? 0 Yes (E) No $0.00
Travel Documentation Fee: ITRAVDOC $47.00
Strom Motion Fee: IBSEISMICR $0.50 Select an Administrative Item
Bldp-Stds Commission Fee: IBCBSC $1.00
;5° CSAIS: $325.50 $0.00 TOTAL FEE: $325.50
Revised: 01/15/2014