09060047 CIT`( OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR.INFORMATION:.,:
BUILDING ADDRESS: PERMIT NO.
11220 TERRA BELLA DR SATYENDRA DHINGRA GITTY 09060047
OWNER'S NAME: DH INGRA PERMIT ISSUE DATE
S A CONTROL N0.
11L7 TT IVT
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
u a p LICENSED CONTRACTOR'S DECLARATION
U U I hereby affirm that I am licensed under provisions of Chapter 9(commencing Job Description
z ty with Section 7000)of Division 3 of the Business and Professions Code,and my license is
'_may in full farce and effect KITCHEN/DINING REMODEL NON—STRUCTURAL) FINAL INSP
? License Class_ Liu.N
m Date Contractor
ARCHITECT'S DECLARATION
mU 1 understand my plans shall he used as public records
a
O H Licensed Professional
n y OWNER-BUILDER DECLARATION
a 1 hereby affirm that 1 am exempt from the Contactors License Law for the
00 following reason.(Section 7031.5,Business and Professions Cade:Any city or county
y m FZ which requires a permit to construct,alter,improve,demolish,or repair any structure
Z y prior to its issuance,also requires the applicant for such permit to file a signed statement
=a0 that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area Valuation
x F- (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
i that he is exempt therefrom and the basis for the alleged exemption.Any violation of $15000
Section 7031.5 by arry applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
not marc than five hundred dollars(5500). 35621007 . 00
❑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
and Professions Code:The Contractors License Law does not apply to an owner of Required Inspections
property who builds or improves thereon,and who does such work himself or through his
own employees,provided that such improvements are not intended or offered for sale.If,
however,the building or improvement is sold within one year of completion,the owner-
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
6)'as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business and Professions Code:)The Contracwrs Li-
ccnse Law does not apply to an owner of property who builds or improves thereon,and.
who contracts for such projects with a contraciar(s)licensed pursuant to the Contractor's
License Law.
❑I am ,B&PC for this rc an
Owner Dare
CE MPENSA DECLARATION
I hereby affirm un natty of ped one of the following declarations:
I have and will maintain a Certificate of Consent to self-insure for Workers Compen-
.ation,as provided for by Section 3700 of the Labor Code,far the performance of the
work for which this permit is issued.
❑1 have and will maintain Worker's Compensation Insurance,as required by Section
3700 of the Labor Code,for the performance of the work for which this permit is issued. '
My Worker's Compensation Insurance carrier and Policy number arc:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars($100)
or less.)
I certify that in the performance of Ih work for hich is permit is issued, shall n
employ any person in a
Laws of Caliromia
Applicant
NOTICE TO AP NT:If, flet making this Con't or lizemption,you should
become subject to the Worker's Compcnsatian provisi0 of the Labor Code,you must
Z forthwith comply with such provisions or this permit shad]be deemed revoked.
Z O CONSTRUCTION LENDING AGENCY
F-t � I hereby affirm that then:is a conswcunn!coding agency for the performance of
p: > the work for which this permit is issued(Sec.3097,Civ.C.)
W to L endces Name
Z Lenders Address
U Q 1 certify that I have read this application and stare that the above information is
" — correct I agree to comply with all city and county ordinances and state taws relating to
0 V building construction,and hereby authorise representatives of this city to enter upon the
W above-mentioned property for inspection purposes.
CJ~ (We)agree to save,indemnify and keep harmless the City of Cupertino against
liabilities,judgments,costs and expenses which may in any way accrue against said City '
U Z in consequence
Re-roofs
Signature rApplican Co for ate
H1 OUS MATERIALS CLosu Type of Roof
Will the applicant o uturc building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Code,Section 25532(a)?
❑Yea ❑r All roofs shall be inspected prior to any roofing material being Installed.
Will the applicant or future building occupant use equipment of devices which If a roof is installed without first obtaining an inspection,I agree to remove
tit ha72rdaus air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
.istrict?
❑Yes o
1 have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health&Safct Codc",c uo 25505,25533 and 534.1 underscv d that if the building
docs not cure a a' roc sihilily to notify the occup t of the
requirements t prir to i u f a Certificate of cupan . Signature of Applicant Date
Owner or aulhon-rcd age ate
All roof coverings to be Class'¢"'or better
co(? (:)�p
CITY OF CUPERTINO
CITY OF
CUPERTINO GENERAL BUILDING
PERMIT APPLICATION FORM
APN #-3� OCA a DateF5J a0-0-9;
Building Address:
11 Z,2- ALPEPITWO
Mailing Address (if different from building address):
Owner's Name:
6)4�
Fax:
Contractor License#:
Cupertino Business License #:
Contact: Phone:
Fax:
Residential Commercial F-1 p
Job Description: K�i � o 1 Pj (\) C-V—
N �-L
Building Permit Info:
Bldg ❑ Elect ❑ Plumb ❑ Mech ❑
Type of Construction (Usage Class): Occupancy Type:
1-A, 1-13II/III/V-A IUIII B, IV-HT, V-B - ]-- R-'
Valuafn: 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:
For help, contact Build it Green at www.buildit reen.or ��
Revised 02/05/09
CITY OF CUPERTINO
CITY OF GENERAL BUILDING APPLICATION
CUPEkTINO
FEE SCHEDULE
Quantity/Sf Fee 11D Fee Description FeePermit Type
Group 1GENRES or
1GENCOM
1 BBOILERI For the installation or relocation of ea M
boiler/compressor to & including 3
' horsepower, or ea absorption sys to &
incl 100,000 Btu/h (29.3kw)
1 BBOILER2 Installation/relocation of ea M
boiler/compressor`'over 3 horsepower
to & incl 15 horsepower, or ea
absorption sys over 100,000 Btu/h
11313OILER3 Instal I ation/relo cation of ea M
boiler/compressor over 15 horsepower
to & incl 30 horsepower, or ea
absorption sys over 500,000 Btu/h to
& incl 1,000,000 Btu/h
1 BBOILER4 Instal I ation/rel ocati on of ea M
boiler/compressor over 30 hosepower
to & incl 50 horsepower, or for ea
absorption sys over 1,000,000 Btu/h to
& incl 1,750,000 Btu/h . . 1 0
113130ILER5 Instal I ation/rel ocation of ea boiler or M
refrigeration compressor over 50
horsepower, or ea absorption sys over
1,750,000 Btu/h
1 BAPPLOTH For ea appliance or piece of equip M
regulated by this Code but not classed
in other appliance categories, or for
which no other fee is listed in this
code.
1 ELECINSP Other Electrical Inspections (per hour) E
1MECHINSP Other Mechanical Inspections (per M
hour) .
1PLMBINSP Other Plumbing &. Gas Inspections P
(per hour)
1 MEETINGI HR Application Meeting B
2of5