12090259CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 1173 STAFFORD DR
CONTRACTOR: SERVICE CHAMPIONS
PERMIT NO: 12090259
OWNER'S NAME: PINAKI& MEENAKSI 11 MUKERJI
7020 COMMERCE DR
DATE ISSUED: 09282012
OWNER'S PHONE: 4088737302
PLEASANTON, CA 94588
PHONE NO: (925) 4444444
.K,) LICENSEDCO\fRACI'OR'S DECLARATION
JOBDF,SCRIPTION: RESIDEN71AI. COSIMF,RCIAI,
License Class C T'd Lic. 9 'VI -7t)�V
REPLACE 10 SUPPLY DUCTS
*M�Contractor �%Ute-Pi 71`611)5 Date q -7'b
hereby affirm that 1 am licensed under the provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business S Professions
Code and thin 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: $3953
performance of the work for which this permit is issued.
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
AM Number: 36206027.00
Occupaney'fype:
permit is issued.
APPLICA\ I' CER'I'IFIG\TION
I certify that I have read this application mid 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 DAY �F2�� LAST CALLED INSPECTION.
indemnify and keep harmless the City of Cupertino against liabilitics,judgmcnts,
costs, and expenses which may accrue against said City in consequence of the
1
/
granting of this permit. Additionally, the applicant understands mid will comply
Issued by: Date: I�ti
with all non -point source regulations per the Cupertino Municipal Code, Section
RE -ROOFS:
9.18.
R - Z<S _1 Z
Signature l Date
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.
❑ O\VNF,R-RUILDER DECLARATION
Signature of Applicant: Date:
hereby affirm that 1 am exempt from the Contractor's hicuisr haw for one of
the following two reasons:
ALI, ROOF COVERINGS TO BF 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)
1, as owner of the property, am exclusively contracting with licensed contractors to
IIA7,ARDOUS MATF.RLU S DISCLOSURE
construct the project (Sec.7044, Business d Professions Code),
I have read the hazardous materials requirements under Chapter 6.95 of the
California Ilcallh S Safety Code, Sections 25505, 25533, and 25534. 1 will
hcreb)' 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 Aren 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, Secti s 25505, 2553 and 25534.
Section 3700 of the Labor Code, for the performance of the work for which this
Date:
Owner or authorized agent:
permit is issued
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 Imus 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.
w'ork's for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
AI'PI-ICANTCER'1'IFICA'1'I0N
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 Imes 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
ARCIIITF.CI"S DFCLARATION
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
CUPERTINO
CONTRACTOR / SUBCONTRACTOR LIST
Building Department
City Of Cupertino
10300 Torre Avenue
Cupertino, CA 95014-3255
Telephone: 408-777-3228
Fax: 408-777-3333
JOBADDRESS: 0-73 �rAP?A/ /^
PERMIT#
OWNER'SNAME: 0eAc4 dt1 L -e I
PHONE# L) S73-7302
GENERAL CONTRACTOR: 5pju «2
BUSINESS LICENSE #
ADDRESS: -1M0 ,OIN4VLe rc,-,p, 17j-
CITY/ZIPCODE:2-_aSaA H tfSI-
Our municipal code requires all businesses working in the city to have a City of Cupertino business license.
NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE
GENERAL CONTRACTOR AND ALL SUBCONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO
BUSINESS LICENSE. �I�>��
I am not using any subcontractors: {
Signature Date
Please check applicable subcontractors and complete the following information:
Owner / Contractor Signature
Date
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
Septic Tank
Sheet Mctal
Sheet Rock
Tile
Owner / Contractor Signature
Date
CITY OF CUPERTINO
FEE ESTIMATOR - BUILDING DIVISION
JAFADDRFSS:
1173 STAFFORD DR
DATE: 09/28/2012
RFVIEWFD BY: MENDEZ
Alech. Permit Fee:
APN:
BP#:
*VALUATION:
$3,953
*PERMIT TYPE: Building Permit
PLAN CHECK TYPE: Alteration / Repair
PRIMARY SFD or Duplex
USE:
Elec. hup. Pec:
PENTAMATION
PERMIT TYPE:
NVORK
REPLACE 10 SUPPLY DUCTS
SCOPE
NOTE: This estimate does not includejees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School
District. etc.). These fees are teased on the mrelimdnan, information available and are only an estimate. Contact the Dept for athin'I info.
FEE ITEMS (Fee Resolution 11-053 En 7/I/11)
Alech. Plan Check
Plumb. Plan Check
Elec. Plan Check
Alech. Permit Fee:
Plumb. Permit Fee:
Mee. Permit Pee:
Odter,ticch. Insp.
Other Plumb Insp.
Other Elce. Imp.
Mcch. bap. Fee:
Plumb. hup. Fee.:
Elec. hup. Pec:
NOTE: This estimate does not includejees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School
District. etc.). These fees are teased on the mrelimdnan, information available and are only an estimate. Contact the Dept for athin'I info.
FEE ITEMS (Fee Resolution 11-053 En 7/I/11)
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee:
$0.00
Select a Misc Bldg/Structure
or Element of a Building
Suppl. PC Fee: Q Reg. Q OT
FO.OThrs
$0.00
PME Plan Check:
$0.00
Permit Fee: Hourly Only? O Yes Q No
$0.00
Suppl. Insp. Fee:Q Reg. C) OT
1 0.0
1 hrs
$0.00
PME Unit Fee:
$0.00
PME Permit Fee:
$0.00
Constntction Tax.
Admit istrative Fee:
O
E)
Work Without Permit? O Yes (F) No
$0.00
Advanced Planning Fee:
$0.00
0 hours
$266:00 /STIh'SP
Inspections
Inspection, Hourly
0
0
Travel Uoraonentation.Feer:.
Suong Motion Fee: IBSEISHICR
$0.50
Select an Administrative Item
Bldg Stds Commission Fec: IBCBSC
$1.00
SUBTOTALS:
$1.50
$266.00
TOTAL FEE:
$267.50
Revised: 07/01/2012
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GENERAL PERMIT APPLICATION Iii E 1
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION /y
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
CUPERTINO 2�' �1
(408) 777-3228 • FAX (408) 777-3333 • building(a5,CugerinD.gra \ J
❑ LUMHQJGMECHANICAL ❑ELECTRICAL ❑MISCELLANEOUS
P � / j� /`
PRDIECC ADDRESS I ►,:5 S+/I W V i/ c4 V/ O
OWNER NAME :M•.e-ena /cs/Jd1\vr��'_11 mu lc e i
�q ufi� g73-730--7
E/�""B.
SIBEEF ADOIlESH II�2 L1-�C"Yp or I
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QTY• SLATE. „ ,J_/ _IsV%, I FAX
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CONFACf SAMB
PfiONE .
c -MAR'
STREETADDIUM
CRY,STATE ZIP
FAX
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CONRUCTOR NALpnN/ ze ft - "L /VF`
uc—sNLIC35ETYPEvz�
BUB. LIC .YE
COWANYNAME
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FAX
BIAtEF�VI^/. '06 Q,Y.STA,-��, ?&a- a.rL4 Qys�B
s y/Y-YYfi
ARc=II LFIFTIGINEER NAME LICENSE NUhMER I
BUS LICA
COMPANY NAI.it' E -MAB.
FAX
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S,—t. E_R ADDAEBS CliY. SFATE, ffi
PHONE
USE OF SI SF0 a DUPLEX ❑ MULT4EAl�.Y
PRCUEL7IN WB.DWW ❑YES PROF..CTtN ❑YES
AA:.S FCDOD TONE ❑NO
STHE a1DO nN ❑YES
EIt]DFR H[1ME] ❑NO
BUILDING: 000WAERQAL
[BtBAN pRF�FACc ANO
DFSCRIMON OF WORK
TOTAL VALUATION: Scr52 1 UV RECIIVED BY:
By m9 s gnarae be ow. I oe dfy m each a: the �Ilaw rg I am the pcapCy mvrer or a¢d mad aim[ m ae oo he pmpa y aw¢ds vhalf I have ead This
WMt ve"i-`Y ;. is acema'a: I agree m wrnph/ Wi[h all mplinble local
appliladm and Lhe info ua I have providcd is Wm L j have read the Dew-ipd= Of a=d
cadccaand statclaws teladDg m bmldirgt =fL ods(I Ives ofCoperao m eater the above-ides¢fi pam' fm itssperaoa pafpasei
maa
Siguhse afApp6cacat/A6m1
SUPPLEMENTAL INFORMATION REQUIRED OFFICE USE ONLY
❑ OVER-Tux-COUXTM
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< ❑ LARGE
❑ MAJOR
MEPMsc-Apa_2011.doc revised 06/31/11