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13030147 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 22621 POPPY DR CONTRACTOR:ROMANO ELECTRIC PERMIT NO:13030147 OWNER'S NAME: RAJ&SUJATHA KRISHNAN 2198 LAUREL DR DATE ISSUED:03/27/2013 OWNER'S PHONE: 4083935054 SANTA CLARA,CA 95050 PHONE NO:(408)564-0583 13 LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL COMMERCIAL License Class CiL b Lia# � !2�G INSTALL(N)ELECTRICAL WIRING AND(N)DEDICATED �fD Q i CIRCUIT FOR FUTURE EV CHARGING SYSTEM IN Contractor f? . � e Alegi . d27, 13 GARAGE I hereby affirm that I am licensed under the provisions of Chapter 9 AREA&ADD 1(N)OUTLET RECEPTACLE (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.permitU issued, Sq.Ft Floor Area: Valuation:$750 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:34212091.00 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 180 DAYS L CALLED INSPECTION. indemnify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which�may accrue against said City inconsequence of the u > 3 Z} j granting of this permit. Additionally,the applicant understands and will comply Date: with all non-point source regulations per the Cupertino Municipal Code,Section 9.18_ RE-ROOFS: Signatur Date/-�;0 i ) 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 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 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 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 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,and 25534. Section 3700 of the Labor Code;for the performance of the work for which this Owner or authorized agent: Date: 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 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(Seca 3097,Civ C.) Lender's Name APPLICANT CERTIFICATION Lender's Address I certify that I have.read this application andatate 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 v\� GENERAL PERMIT APPLICATION \' MEP COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION .10300 TORRE AVENUE•CUPERTINO,CA 95014-3255 CUPERTINO (408)777-3228-FAX(408)777-3333• building(Dcuoeftino.org � MISC PLUMBING ❑MECHANICAL ECMCAL ❑MISCELLANEOUS PROJECT ADDRESS' a l 104>dpy Olt APN n /�J 9 OWNER NAME nJ K VA�"14 rA 4 P OS /J �SE-MAIL `�Y STREETADDRE9Stl+� wit T y�'PP.J n ' • C& �TEnvo �,w cS-6 FAX CONTACT NAMoASC'� �J r J v�� S❑ 4frsS40V,,ww,� O/1O �11 STA ZD FAX O)ANER ❑ OWNER-BUILDER ❑ OWNEAGENT 40!>_0NTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINTEER ❑ DEVELOPER ❑TENANT COACTOR NAME Z � LI SNRO LIC�1S%TSE BUS.LIC# FAX S ��VVIJ�/�S7S +�1�� 00C C �'.STATE,ZIP K.Iy- U PW �7(O T -- V3 ARCNITECTIENGA*EER NAME LICENSE NUMBER BUS.LIC#F oe COMPANY NAME' E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE USE OF ❑SFD.,DUPLEX ❑ MULTI-FAMILY PROJECT IN Wn DLAND ❑ YESPROJECT IN El YES IS THE BLDG AN ❑YES BUILDING: ❑COMMERCIAL URBAN INTERFACE AREA �yNO FLOOD ZONE ❑NO EICHLER HOME? ',i''NO DESCRIPTION OF WORK csZo 6AX I& =ova' .rt,c�s Vis ' TOTAL VALUATION: 4'� EIVED B By my signature below,I certify to each of the following: I am the property owner or authorized agen act on the property owner's f. I have read this application and the information I have provided 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 building construction. I authorize representatives of Cupertino to enter the above-identified propelty for inspection pufposes. Signature of Applicant/Agent Al Date: 7 , gui 3 4----SUPPLEMENTAL INFORMATION REQUIRED OFFICE USE ONLY OVER-THE-COUNTER L I- ❑ EXPRESS .4 U u ❑ STANDARD U ❑ LARGE 4 ❑ MAJOR MEPMiscf4pp_2011.doc revised 06/21/11 CITY OF CUPERTINO FEE ESTIMATOR-BUILDING DIVISION ADDRESS: 22621 POPPY DR DATE: 03/27/2013 REVIEWED BY: MELISSA APN: 342 12 091 BP#: "VALUATION: $750 *PERMIT TYPE: Electrical Permit PLAN CHECK TYPE: Alteration/Addition/Repair PRIMARY SFD or Du lex PENTAMATION 1 REAP? USE: p PERMIT TYPE: WORK INSTALL N ELECTRICAL WIRING AND N DEDICATED CIRCUIT FOR FUTURE EV CHARGING SCOPE SYSTEM IN GARAGE AREA&ADD 1 (N) OUTLET RECEPTACLE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Special Circuits 1BREMMISC 1 # $133 Recep/Switch/Outlets 1BREMRECEP 1 # $45 TOTALS: $178.00 r Xfech.Plan Check Phimb,Plan Check Elec.Plan Check 0.0 hrs $0.00 blech. Permit Fee Plumb. Permit Fee: Elee.Permit Fee: lEPERMIT Flfib,h. ech.Insp. Other Plumb Insp. =F1 Other Elec.Insp. 0.0 hrs $45.00 Insp.Tee. Plumb. Insp.Fee: Elec.Insp.Fee: NOTE:This estimate does-not include fees due to other Departments(Le.Planning,Public Works,Fire,Sanitary Sewer District,School District,etc). These&es are based on the prelimina information available and are only an estimate Contact the Dept for addn'l info. FEE ITEMS(Fee Resolution 11-053 E . 7/1/12) FEE QTY/FEE MISC ITEMS Plan Check Fee: Suppl. PC Fee PME Plan Check: $0.00 Perin it Fee: Suppl. Insp Fee PME Unit Fee: $178.00 PME Permit Fee: $45.00 Construction Tax: Administrative Fee: 1ADMIN $42.00 Work Without Permit? ® Yes (E) No $0.00 Advanced Planning Fees: Travel Documentation Feer ITRAVDOC $45.00 Strong Motion Fee: 1BSEISMICR $0.50 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $1.00 tro NIM $311.50 $0.00 TO : $311.50 Revised: 01/01/2013