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15080218�t CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 1065 COLONY HILLS LN CONTRACTOR: ALI'S CONSTRUCTION & PERMIT NO: 15080218 REMODELING OWNER'S NAME: GUPTA VINAYAK AND MONIKA 1011 S DE ANZA BLVD DATE ISSUED: 08/31/2015 O ER'S PHONE: 4088576828 SAN JOSE, CA 95129 PHONE NO: (408) 898-6474 11 LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL COMMERCIAL INSTALL TEMP POWER (100 AMPS) License Class_/ Lic. # GO q x-13 3 Contractor G �5 D -0 S �7 U f 41'e-" Date b 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 Sq. Ft Floor Area: Valuation: $2000 erfiormance of the work for which this permit is issued. ave 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: 35930008.00 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 LAST CALLED INSPECTION. 180TZZLy14,;ir indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs, and expenses which may accrue against said City in consequence of the2granting of this permit. Additionally, the applicant understands and will comply Issued by:Date: ✓tl�K1 with all non -point source regulations per the Cupertino Municipal Code, Section 9.18. r G ) �1 I RE -ROOFS: Signature Date D All roofs shall be inspected prior to any roofing material being installed. If a roof is r% installed without first obtaining an inspection, I agree to remove all new materials for inspection. ❑ OWNER -BUILDER DECLARATION 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 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) 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(x) 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 Cu ertino Municipal Code, Chapter 9.12 and I have and will maintain Worker's Compensation Insurance, as provided for by the Health & Safety Code, Sections 25533, and 25534. Section 3700 of the Labor Code, for the performance of the work for which this Owner Date: 't 31 permit is issued. or authorized agent: 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 LENDING AGENCY 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 indemnify and keep harmless the City of Cupertino against liabilities, judgments, ARCHITECT'S DECLARATION 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 Q-A CUPERTINO GENERAL PERMIT APPLICATION JSMA,5 . COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 • build! no a.cupertino.org ❑ PLUAffiING ❑ MECHANICAL KECTRICAL ❑ MISCELLANTTHOUS PROJECTADDFESS 105� knY P1,11-5177 ; ��= C"', �� ;T os \ n OWNERNAMB •!� r K/ PHONE (JOIE g 5� / $ ZU C�/JQ,'l,� jLr E-M.AZ STREET ADDRESS �Db C CITY, STATE,ZIPC Ip�-41 %I 0/O J �4 I'S �gl FAX CONTACT NAME /1 L PHONE qe $ 9 8 Gy q K E 1 /SGS STREET ADDRESS ae .4-n2,QI (5 I YP CITY, STATE, ZIP S Am �O fe FAX ❑ OWI. -t ❑ O)AINER-BU11MER ❑ 07.1\-iM-AGF-T fi�CO>\TRACTOR ❑ CO'`TRACTORAGETT ❑ ARCHITECT ❑ ENGATEER ❑ D=,TWPER ❑ TE ANT CONTRACTOR NA14E Q C� LICENSE NUMBER r+/O(j/J LICENSE TYPE (3 �[ '( BUS. LIC # COMPANYN.AME 46 S CC ) SI�uCllO�il E-MAIL FAX STREET ADDRESS 01) S Of A,nzo,, (31 1 v0 CITY, STATE, ZIP S� I1 O PHONEq,N� l O T U ARCHITECT/ENGLNEER NALME LICENSE NUMBER BUS. LIC n COMPANY NAME E -MATT, FAX STREET ADDRESS CITY, STATE, ZIP PHONE USE OF or DUPLEX ❑ MULTI-F.ATaY PROJECT LN WI DLAND ❑ � cS PROJECT LN B=L\1G: COMMERCLAL I URBAN INTERFACE AREA NO FLOOD ZONE ❑ `.-s ❑ i�19 IS THE BLDG AN ❑ YES EICHLERHOMEI ❑ NO DESCRIPTION OF WORK G/ / ,m R 6,e?( Je-� TOT L VALUATIONT: By my signature below, I certify to each of the following: I am the property owner or authorized agent to act on the froperty owner's behalf. I have read this application and the information I have vided is correct 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 ing onstru ion. I authorize representatives of Cupertino to enter the above -identified property for inspection purposes. Signature of Applicant/Agent: Date: 0 usl / I SUPPLEMEN AL INFORMATION REQUIRED _CE USE Y: MFR -THE -COUNTER" OR MEFAIt'iscApp_2011.doc rei,fsed o6/21/II ,r CITY OF CUPERTINO 0%034 Imo -/i FEE ESTIMATOR — BUILDING DIVISION LMADDRESS: 1065 Colony Hills Ln AMPS DATE: 08/31/2015 REVIEWED BY: PAUL imN APN: 359 30 008 BP#: 'VALUATION: 1$2,000 'PERMIT TYPE: Minor Building Permit <=600 PLAN CHECK TYPE: Temporary Power ''RIMIRl' 1'SF: SFD or Duplex Permit Fee: PENTAMATION 1REAP14 PERMIT TYPE: WORK ower 100 Amps) [tgpLtemp SCOPE PME Unit Fee: APPLIANCE / EQUIP TYPE FEE ID AMPS VOLTS alech. Permit Fee: BP FEES Elec. Permit Fee: IEPERMIT Temporary Power 1 ERT<200 100 <=600 Plunib. Lisp. Fee: $48 Permit Fee: :Szrpp1. Insp Fee PME Unit Fee: $48.00 PME Permit Fee: $48.00 Construction Tax: Administrative Fee: Work Without Permit? O Yes (j) No $0.00 Advanced Planning Fees: ° i Travel Documentation Fee: 1TRAVDOC $48.00 Strong; Motion Fee: IBSEISMICR NOTE: This estimate does not include fees due to other Departments (Le. Planning, Public Works, Fire, Sanitary Sewer District, School District. etc). These fees are based on the nreliminary information available and are only an estimate. Contact the Dept for addn 7 info. FEE ITEMS (&e Resolution 11-053 a' %%1 '132 . flan Check QTY/FEE "!an Check alech. Permit Fee: Plum- Elec. Permit Fee: IEPERMIT OtherA9ech. Insp. Other ,"Iumh ln,rP. r Liac. Insp. $48.00 11ech. Inup. Fee: Plunib. Lisp. Fee: C. Imp. Fee: NOTE: This estimate does not include fees due to other Departments (Le. Planning, Public Works, Fire, Sanitary Sewer District, School District. etc). These fees are based on the nreliminary information available and are only an estimate. Contact the Dept for addn 7 info. FEE ITEMS (&e Resolution 11-053 a' %%1 '132 FEE QTY/FEE MISC ITEMS Plan Check Fee: Suppl. PC Fee Plumb.l Mlech./Elec Permit Fee: :Szrpp1. Insp Fee PME Unit Fee: $48.00 PME Permit Fee: $48.00 Construction Tax: Administrative Fee: Work Without Permit? O Yes (j) No $0.00 Advanced Planning Fees: ° i Travel Documentation Fee: 1TRAVDOC $48.00 Strong; Motion Fee: IBSEISMICR $0.50 '� Select an Administrative Item Bldy Stds Commission Fee: IBCBSC $1.00 SUBTOTALS: 1 $145.501 $0.00 TOTAL FEE: $145.50 Revised: 07/02/2015