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13110040 1"111111t"M CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 19959 STEVENS CREEK BLVD CONTRACTOR:TBD-TO BE PERMIT NO: 13110040 DETERMINED OWNER'S NAME: PANT SUSHMA DATE ISSUED: 12/17/2013 OWNER'S PHONE: 4082608115 PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL F] COMMERCIAL F] �( TPUMPS-T.I. TO INSTALL NEW EQUIPMENT WITH License Class t S, Lic.t1_ / 6,�V3 1 Q-3 RELATED MECHANICAL,ELECTRICAL,AND PLUMBING. Contractor .}.A L'p j1/. (/1J =i L 4 REV# 1 -RECONFIGURE SERVICE AREA-ISSUED 1/14/14 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 i performance of the work for which this permit is issued. Sq.Ft Floor Area: Valuation:$20000 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:31621090.19959 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 Issued by: Date: with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. _ �% 15� r RE ROOFS: Signature Date jT All roofs shall be inspected prior to any roofing material being installed.If a roof is installed without first obtaining an inspection,I agree to remove all new materials for inspection. ❑ OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for one of Signature of Applicant: Date: 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) 1,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. 1 will 1 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 1 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 Cupertino Municipal Code,Chapter 9.12 and . I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sections,550,25533,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,1 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 1 certify that 1 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 Iiabilities,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 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 19959 STEVENS CREEK BLVD CONTRACTOR:TBD-TO BE PERMIT NO: 13110040 DETERMINED OWNER'S NAME: PANT SUSHMACS Gryt DATE ISSUED: 12/17/2013 W ONER'S PHONE: 4082608115 PHONE NO: 1 ❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL COMMERCIAL ❑ TPUMPS-T.I.TO INSTALL NEW EQUIPMENT WITH License Class Lic.# 3 Y-3 RELATED MECHANICAL,ELECTRICAL,AND PLUMBING. Contractor -'*dUAuW. ate 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 performance of the work for which this permit is issued. Sq.Ft Floor Area: Valuation:$20000 1 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:31621090.19959 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 PE IT ISSUANCE OR to building construction,and hereby authorize representatives of this city to enter 1 upon the above mentioned property for inspection purposes. (We)agree to save 180 DAYS FRO LED INSPECTION. i 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 Iss Date: 17, A with all non-point souroe regulations per the Cupertino Municipal Code,Section 4000, ; i 9.18. y RE-ROOFS: Signature 6,h �""��` Datei Z'l ! ZOl3 All roofs shall be inspected prior to any roofing material being installed. If a roof is installed without first obtaining an inspection,I agree to remove all new materials for inspection. ❑ OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for one of Signature of Applicant: Date: 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(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 Cupertino Municipal Code,Chapter 9.12 and I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sections 25505,25533,a�5534. Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agent: --�}— 1 Dated-ZA T-7 3 permit is issued. o 1 certify that in the performance of the work for which this permit is issued,1 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 1 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 CONSTRUCTION PERMIT APPLICATION '�O COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION `©� 10300 TORRE AVENUE• CUPERTINO,CA 95014-3255 CUPERTINO (408)777-3228• FAX(408)777-3333• buildingCo)cupertino.org ❑ NEW CONSTRUCTION ❑ ADDITIONALTERATION/TI ❑ REVISION/DEFERRED ORIGINAL PERMIT# PROJECT ADDRESS IN# 3(6 v r OWNERNADIE � SV S�mQ. P E-MAIL STREET ADDRESS � / Ow �t _s� CITYsi 10 , ^TE IP CONTACT NAME �� W PHC�N11� l V E-MAIL (f/ t u T V ov7 jO s. Co.— STREET ADDRESS ZIP FAX CITY,STATE, Lr�-1 �e- 1�^ S c s 1:1OWNER ❑ OWNER-BUILDER 1:1oWNERAGEN'T ElCO\TRACTOR E]CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME LICENSE NUMBER LICENSE TYPE BUS.LIC# COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE ARCHITECT/ENGINEER NAME ` LICENSE NUMBER BUS.LIC# V HZLI�i a COMPANY NAME �/ E-MAIL // FAX �%viA✓t f"i3.1 c` S� Ol' 'TM''1 Co�j0 � CG�M STREET ADDRESS CITY,STATE,ZIP PHONE -72 -7 �tA S%7 -7� DESCRIPTION OF NVORK EXISTING USE PROPOSED USE CONSTR TYPE #STORIES USE v USE TYPE OCC. SQ.FT. VALUATION(S) EXISTG NEW FLOOR DEMO TOTAL T', I , AREA AREA AREA NET AREA !6� 1� �bo BATHROOM KITCHEN OTHER V '/ v REMODEL AREA REMODEL AREA REMODEL AREA PORCH AREA DECK AREA TOTAL DECK/PORCH AREA GARAGE AREA: DETACH ❑ATTACH #DWELLING UNITS: IS A SECOND UNIT ❑YES SECOND STORY ❑YES BEING ADDED? 1]NO ADDITION? ONO 0 PRE-APPLICATION ❑YES IF YES,PROVIDE COPY OF IS THE BLDG AN 1]YES REC ME 6TAL VALUATION: PLA\T'WGAPPL# r]N0 PLANTING APPROVAL LETTER EICHLER HOME? E]NO By my signature bel*w,I certify to each of the following: I am the prop ow er or authorized agent to t on Xe property owner's behalf. I have read this application and the i#formation I have provided is correct 1 have rea e De r ption of Work and verify accurate. I agree to comply with all applicable local ordinances and state.1aws relating to building construction a r=sentatives of Cupertino to enter the above-identified property for inspection purposes. Signature of Appli0*A/Agent: Date: SU PLEMENTAL INFORMA ON REQUIRED PLAN CHECK TYPE ROUTING SLIP New SFD or Multifamily dwellings: Apply for demolition permit for ❑ OVER-TILE-COUNTER ❑ BUILDING PLAN REVIEW existing building(s). Demolition permit is required prior to issuance of building permit for new building. ❑ EXPRESS ❑ PLANNING PLAN REVIEW _Commercial Bldgs: Provide a completed Hazardous Materials Disclosure ❑ STANDARD ❑ PUBLIC WORKS form if any Hazardous Materials are being used as part of this project. ❑ LARGE ❑ FIRE DEPT _Copy of Planning Approval Letter or Meeting with Planning prior to ❑ NIAJOR ❑ SANITARY SEP'ER DISTRICT submittal of Building Permit application. - ❑ ENVIRONMENTALHEALTtt B1dgApp_2011.doc revised 06/21/11 ' I CITY OF CUPERTINO FEE ESTIMATOR- BUILDING DIVISION ADDRESS: 19959 STEVENS CREEK BLVD DATE: 11/07/2013 REVIEWED BY: MELISSA APN: 316 21 090 BP#: C 'VALUATION: $20,000 *PERMIT TYPE: Building Permit PLAN CHECK TYPE: Tenant Improvement PRIMARY Commercial Building PENTAMATION 16 1-1 USE: PERMIT TYPE: WORK TPUMPS -T.I. FOR RECONFIGURE AREA. NO STRUCTURAL & NO FOOD PREP SCOPE OCCUPANCY TYPE: TYPE OF FLR AREA PC FEES PC FEE ID BP FEES BP FEE ID CONSTR. s.f. B (Tenant Improvements) II-B,III-B,IV,V-B 660 $2,056.44 IBTIPLNCK $836.48 IBTHNSP TOTALS: 660 $2,056.44 $836.48 MECH,HOURLY Q Yes E) No PLUMB,HOURLY Q Yes Q No ELEC,HOURLY Q Yes Q No ,bti-cA. Permit 1,"'c Fee. Islec. Permit I%ec Other Meeh. Insp. Other Plumb Insp. Uther Flec.Insp. Ll _glee& Insp. ['Ce.- Phanb. Insp.Fee_ Elec.Insp.Fere NOTE: This estimate does not include fees due to other Departments(Le.Planning,Public Works,Fire,Sanitary Sewer District,School District,etc.). These ees are based on the prelimina information available and are only an estimate. Contact the Dept for addn't info. c.:. t,.. FEE ITEMS (Fee Resolution I1-053 Eff 711113) FEE QTY/FEE MISC ITEMS: Plan Check Fee: $2,056.44 Select a Misc Bldg/Structure Suppl. PC Fee: Q Reg. Q OT 0.0 Fhrs $0.00 or Element of a Building PME Plan Check: $0.00 I Permit Fee: $836.48 Supp]. Insp. Fee:Q Reg. Q OT0,0 hrs $0.00 l PME Unit Fee: $0.00 PME Permit Fee: $0.00 , Construction Tax: Administrative Fee: Q Work Without Permit? Q Yes No 0 O $0.00 Advanced Planning Fee: $0.00 Select a Non-Residential 1 /)ocrnnentation Fees: Building or Structure © ; Strong Motion Fee: IBSEISMICO $4.20 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $1.00 SUBTOTALS: ' $2,898.121 $0.00 TOTAL FEE: $2,898.12 Revised: 10/01/2013 Building Department City Of Cupertino 10300 Torre Avenue Cupertino,CA 95014-3255 Telephone: 408-777-3228 CUPERTINO Fax: 408-777-3333 CONTRACTOR/ SUBCONTRACTOR LIST JOB ADDRESS: & PERMIT# ( T, 1 ( 00qo OWNER'S NAME: .-- 514 PHONE# GENERAL CONTRACTOR: BUSINESS LICENSE# h11 � ADDRESS: CITY/ZIPCODE: *Our municipal code requires all businesses working in the city to have a City of Cupertino business license. NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTIONS) WILL BE SCHEDULED UNTIL THE GENERAL CONTRACTOR AND A SUBCONTRACTO"S HAVE OBTA-INED A CITY OF CUPERTINO BUSINESS LICENSE. I am not using any subcontractors.' Signature Date Please check applicable subcontractors and complete the following information: G/ SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets & Millwork Cement Finishing Electrical Excavation Fencing Flooring/Carpeting Linoleum/Wood Glass/ Glazing Heating Insulation Landscaping Lathing Masonry Painting/Wallpaper Paving Plastering Plumbing Roofing i Septic Tank Sheet Metal Sheet Rock Tile `' y i _ Owner/Contractor Signature Date