12030067 CiTY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 22721 MEDINA LN CONTRACTOR!-'- _—_.—._ 'ERNIITNO: 12030067
OWNER'S NAM E: hfBR LLC t C� Cv2t'NST(L�3Cit vA) DATE ISSUED:03/152012
OXVNEIVS PHONE: 6507967982 PHONE NO:
cO- LICENSED CONTRACTOR'S DECLARATIONr
BUILDING PERMIT INFO: BLDG r ELECT r PLUMB
wai-ptc/r-�
LicenseClswMECH RESIDENTIAL COMM1tERCfAL
Co.tra['fLI.1 hereby a1Rnn that 1 um IicenseA under the pJOB DESCRIPTION:A&B-PROPERTY LINE CLEANOUT-REPLACE OLD CAST
(commencing with Section 7000)of Division 3 of the Business&Professions IRON DRAIN WITH NEW ABS
Code and that my license is in full force and effect.
I hereby affirm under penalty of perjury one of the following two declarations:
1 have mid will maintain a certificate of consent to self-insure for Worker's
Compensation.m provided for by Section 3700 of die Labor Code,for the
performance of the work for which this pemiit is issued.
1 have and will maintain Worker's Compensation Insurance,as provided for by �,-,p�
Section 3700 of the Labor Code,for the performance of die work for which this Sq,Ft Floor Area: r tiro:53100
permit is issued.
APPLICANT CERTIFICATION APN Number:34230003. 0 ®. Occupancy Type:
1 certify that I have tend(his application and state that the above information is
correct,I agree to comply widi all city and county ordinances mid state laws relating
to huilding cons(ruetion,and hereby authorize represenmtives of this city to enter
upon lite above mentioned property for inspection purposes. (We)agree to save PER TWM- U3O PiRES IF WORK iS NOT STARTED
indemnify and keep harmless the City of Cupenino against liabilities,judgments,
costs,and expenses which nm ace against said City in consequence of the WITH14- 180 DAYS OF PERMIT ISSUANCE OR
graining of this permit, no y, he app terms understandsand will comply 180 DAYS FROM LAST CALLED INSPECTION.
with all non y+oiin sour reg Ins per the Cupertino Municipal de,S tin
9.18.
DateIssued by Date:if'rZ
Signaturc . � �
OWNER-BUILDER DECLARATION
RE-ROOFS:
7reb rm thm at 1 aexempt front Ute Conto
tracr's License Low for one of All roofs shall be inVected prior to any roofing material lieimg installed.If a roof is
Ic ,(fi
following two reasons: installed without first obtaining ah inspection,I agree m remove all new mmerials for
1,as owner of the propenv,or my ennplovees with wages as their sole compensation, inspection.
will do the work,and the structure is not intended or offered for sale(See.7044,
Business&Professions Code) Signature orApplicant: Date:
1,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business&Professions Code). ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
1 hereby affirm under penalty of perjury one of the following three
declarations: HAZARDOUS MATERIALS DISCLOSURE
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 1 have read the hazardous materials requirements under Chapter 6.95 of the
perfor lance of the work for which this pemiit is issued. California Health&Safety Code,Sections 25505,25533,and 25534. 1 will maintain
I have and will maintain Worker's Compensation Insurance,as provided for by compliance with the Cupertino Municipal Code,Chapter 9.12 and floe Health&
Section 3700 of the Labor Code,for the pet formatce of(lie wort:for which this Safety Code,Section 25532(x)should 1 store or handle hazardous material.
Additionally,should 1 use equipment or devices which emit haadous air
permit is issued. contaminants as definedthe Bay Area Air Quality Management District 1 will
n coultd ice w
I certify that in the performance of lite work for which this pemiit is issued,I shall JVy
maintai ' the Cupertino Municipal Code,Chapier9.12 and the
not employ any person in any inanner so as to becmte subject to the Worker's Health&Saf Cm .Sections 255115,25533,and 255
Compensation lanes of California. If,after making this certificate of exenmption,I
beconhe subject in the Worker's Compensation provisions ofte labor Code,i must Ownern nth ed it it(:
forthwith comply with such provisions or this permit shall be devoted revoked Date:
APPLICANT CF-RTIFICAT-ION CONSTRUM. ON L.ENDINC.AGGNC11
I certify that I have read this application mid state that the above information is I h y affirm that there is a construction lending agency for the performance of work's
correct.I agree n comply with all city ane!county ordinances and state laws n ng R i which this permit is issued(Sec.3097,Cir C.)
Rt building construction,and hereby authrrize representatives of this city to enter Lender's Name
upon the above mentioned property for inspection purposes.(We)agree to save
indemnify and keep harmless the by ot'Cupertino against liabilities,judgments, Lender's Address
costs,and expenses which may accrue against said City in consequence of tate
granting of this pemmit.Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section ARCHITECT'S DECLARATION
9.18. I understand my plans shot[be used as public records.
Signature Date Licensed Professional
CITY OF CUPERTINO
6 ITEMS OF 6 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . : . : 34230003 .00
DATE ISSUED. . . . . . . : 03/15/2012
RECEIPT # . . . . . . . . . : BS000016276
REFERENCE ID # . . . : 12030067
SITE ADDRESS . . . . . : 22721 MEDINA LN
SUBDIVISION . . . . . . .
CITY CUPERTINO
IMPACT AREA . . . .
OWNER . . . . . . . . . . . . : MBR LLC
ADDRESS . . . . . . . . . . : 20902 GARDEN GATE DR
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
RECEIVED FROM . . . . : VIPIN GUPTA
CONTRACTOR . . . . . . . : TBD - TO BE DETERMINED LIC # 00096
COMPANY . . . . . . . . . . : TBD - TO BE DETERMINED
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . . ,
TELEPHONE . . . . . . . . :
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
-ADMIN HOURS 1 . 00 41. 00 0 . 00 41 . 00 0 . 00
1BCBSC VALUATION 5, 100 .00 1. 00 0. 00 1 .00 0 . 00
1BSEISMICR VALUATION 5, 100 .00 0 .51 0 .00 0 .51 0 . 00
1PPERMITFE FLAT RATE 1 .00 - 44 .00 0 .00 44 .00 0 .00
1PRSEWER UNITS 1 .00 22 .00 0.00 22 .00 0.00
1TRAVDOC FLAT RATE 1 .00 44 . 00 0 .00 44 .00 0 .00
---------- ---------- ---------- ----------
TOTAL PERMIT 152 .51 0 .00 152 .51 0 .00
METHOD OF PAYMENT AMOUNT ,REFERENCE NUMBER
----------------- --------------- --------------------
CREDIT CARD 152 . 51 AMEX
---------------
TOTAL RECEIPT 152 .51
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
106 SEWER & WATER 202 UNDERFLOOR PLUMBING
301 ROUGH PLUMBING 4.00 SEWER/LATERAL
507 FINAL PLUMBING
b-7
GENERAL PERMIT APPLICATION M E P
COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION
10300 TORRE AVENUE •CUPERTINO, CA 95014-3255 M I
CUPERTINO (408)777-3228 • FAX(408)777-3333• buildinaecuoer8no.orD
LUMHL`IG sc
❑MECHA.NICAL ❑1=CT2G4L. ❑MISCaL ANEOUS
PROJECTADORESS 2,9-77-1 / P. AMI ' 1.�^ O /
\ / OWNIANAME LL d(/Pl, i "`°'6T . 9 6 2 L E-MAILV (�
S1R�TADDRESS / TTY. ST F, I/4V lJr1 Q� FAX
Ly 1
CONTACT NAME PHONE E.MAH
STREET ADDRESS CITY.STATE, ZrP FAX
❑OWNER ❑ DWNm-BUBDm ❑ 0W AGE ❑ caNTR =R ❑CONTRACTORA= ❑ ARtoDTECT ❑E oINEER ❑ DEVELOPm ❑ TFNAN:
Comm.ICCOR NAMELICENSE NUMREA�/l �. TYPRUS.CIC NT
7CU;NAME ^- EMAB.�+7ZJJ6 '!7L OA �•' FAX
STREET ADDRESS `' ` 15-5 .STATE,Z1Pn n /� • P 0 O/r
L ♦ rYL
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ARCHITECT/ENGINEER NAME LICE`ISE NUMBER BUS.LIC N 't
CON(PANY NAME' E-MAIL .AX
STREET ADDRESS CRY,STATE.ZIP PHONE
USE OF ❑SFO wDIJPIJDt ❑ MN.TI-FAMILY PROJERINWED[wN0 ❑ YES I PROIECTIN ❑YES LSTHEBLDGAN ❑YES
BUBDNG: ❑COMMERCIAL. URBAN INTERFACE AREA NO FLoPD ZONE 0N EICHLER Ho.. E [I NO
DESLR=, ON OF WORK ep
e
TOTAL VALUATION: RECEIVED BY:
/\ Hy my signature 6.1 ,I c 'fy m each of the following. I am the property owaer or authorized agent to act on the property owner's behalf I have read this
application and the information I have provided is correctLj have read the Description of Work and verify it is accurate. I agree to conmly with all applicable local
ordinances and state laws relating to building construction. I authorize representatives of Cupertino to enter the above-idendfied property for inspection pu@oses.
Signanue of Appl1=t(Agma Date:
SUPPLEl,=I AL 1NFOR14ATION REQUIRED OFFICE USE ONLY
v ❑ OVER-THE-COUNTER
❑ EXPRESS
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❑ STANDARD
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L ❑ URGE
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J1g'R4fire4pp_201 Ldoc revised 06/21111