15090012vl�
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 21490 VAI AVE
CONTRACTOR: AMERICAN
PERMIT NO: 15090012
RESIDENTIAL SERVICES OF CA
OWNER'S NAME: VIVEK SALGAR
965 RIDGE LAKE BLVD STE 201
DATE ISSUED: 09/01/2015
OWNER'S PHONE: 4087715693
MEMPHIS, TN 38120
PHONE NO: (408) 982-0405
❑ LICENSED CONTRACTOR'S DECLARATION
JOB DESCRIPTION: RESIDENTIAL ❑ COMMERCIAL E]
Cl -765 1537
SPOT REPAIR ON MAIN SEWER LINE.
License Class Li,. #
Contractor D)JU,&rh SV)d c ✓ Date q — I 1
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
Sq. Ft Floor Area:
Valuation: $6900
performance of the work for which this permit is issued.
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
permit is issued.
APN Number: 36205022.00
Occupancy Type:
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
�/
y: Issued b vii f l Date: '
granting of this permit. Additionally, the applicant understands and will comply
d
with all non-point source regulations per the Cupertino Municipal Code, Section
9.18.
Signature Date 1 7
RE-ROOFS:
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
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. 1 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, 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, 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 (Sec. 3097, Civ C.)
Lender's Name
Lender's Address
APPLICANT CERTIFICATION
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 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
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
ARCHITECT'S DECLARATION
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
GENERAL PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 Amalk
(408) 777-3228 • FAX (408) 777-3333 • building(-)cupertino.orgf.,� a ��ts L M I
�{" }.ELUAfBING ❑ MECHANICAL ❑ ELECTRICAL ❑ bESCELLANEOUS
PROJECT .ADDFESSI a ^' T. C i APN
0%VNTRN'A1✓E I V L j\ ��2A R
PHONEgog.��I - �L9 3 E-NL4IL
STREET AV DDRESS ' 1 ` I CITY, STATE, ZIP �� y FP.X
2If1 Q J
CONTACT NAME v�1 i D� �Q _ ^ PHOTyo!- ( G 6- S II L E-ViiAIL
STREET.ADDRESS {� rf �J CITY, STATE, ZIP O� FAX
❑ ow.,,ER ❑ OV,R.'ER-3UII_DER ❑OWNER AGENT ❑ CONTRACTOR ❑ CO-.17RACTOR. AGENT ❑ ARCH ECT ❑ ENG= --.R ❑ DEQ -LOPER ❑ TENAI`T
CONTRACTOR NAJ1IE I l TA 1 1 ✓ LICENSE NUMBER / 5-, 5-/ LTY
I=SE PE ` BUS. LIC
COMPANY N.AJ� n 6 g Z. _5C, U e P JR dot � E-M.AIL �L `J FAX
STREET ADDRESS CITY, STATE, ZIP P N
06 PARA(Ink) I -'-am 305- c off - e � • l�
ARC=ECT/ENGL EER NAME LICENSE NUMBER BUS. LIC n
COMPANY NAME E-MAIL FAY,
STREET ADDRESS CITY, STATE, ZIP PHONE
USE OF SFD or DUPLEX ❑ MULT1-F.A1,=Y PROJECT N WILDL.AND ❑ YES PROJECT A' ❑ YES IS THE BLDG AN Q YES
B=LNIG: ❑ COMMERCIAL I URBAN LNTERFACE AREA I.'O FLOOD ZONE NO EICHLER HOME? NO
DESCP.IPTION'OFWORK �Gj f�P Cr
TOT?1 VALUATION' RECEI
VE➢B1'
Lquo
By my signature below, I certify to each of the following: I am the property owner or authorized agent to act on the property owner's behalf. 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 g co tru lio. I authorize representatives of Cupertino to enter the aabove-identifi�property for inspection purposes.
Signature of Applicant/Agent: Date:
PPLEn4ENTAL INFORMATION REQUIRED
g, OFFICE USE ONLl
0}'ER THE�COUITER' �
R � STANDa.RD
U
0 I4RGE
� . 3A10 R
RfEPA7isc.4pp_2011.doc remised 06121/11
CITY OF CUPERTINO
FEE ESTIMATOR — BUILDING DIVISION
APPLIANCE / EQUIP TYPE
21490 VAI AVE
DATE: 09/01/2015
REVIEWED BY: SEAN
IlaADDRESS:
APN:
BP#:
*VALUATION: 1$6,900
*PERMIT TYPE: Plumbing Permit
PLAN CHECK TYPE: Alteration / Addition / Repair
PRIMARY SFD or Duplex
USE:
#
PENTAMATION 1 RPSS
I PERMIT TYPE:
WORK
SPOT REPAIR ON MAIN SEWER LINE.
SCOPE
Suj:)p/. Insp Fee
APPLIANCE / EQUIP TYPE
FEE ID
Plumb. Plan Check 0.0 1 hrs $0.00
QTY
UNITS
BP FEES
Sewer, Sanitary
1PRSEWER
Other Elec. Rasp. Ll I
1
#
$25
Permit Fee:
Suj:)p/. Insp Fee
PME Unit Fee:
$25.00
PME Permit Fee:
$48.00
rx,,,!,nction Tax:T7
Administrative Fee: (ADMIN
$45.00
Work Without Permit? Yes (F) No
$0.00
TOTALS:
A
Travel Documentation Fee: ITRA VDOC
$25.00
Strong Motion Fee: IBSEISMICR
NUTS': 'Phis estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School
District. etc). These fees are based on the Dreliminary information available and are nn/v an e.ctimato_ rinitart the 1)ent for addn'l info_
FEE ITEMS (Fee Resolution 11-053 Eff 7/1;13)
ifech. Plan Check
Plumb. Plan Check 0.0 1 hrs $0.00
Li7ec.. Plan ChHck
Mech. PerrraifFe�e:
Plumb. Permit Fee: IPPERMIT
Other Alerh. Insp.
Other Plumb Insp. 0.0 hrs $48.00
Other Elec. Rasp. Ll I
PME Plan Check:
$0.00
NUTS': 'Phis estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School
District. etc). These fees are based on the Dreliminary information available and are nn/v an e.ctimato_ rinitart the 1)ent for addn'l info_
FEE ITEMS (Fee Resolution 11-053 Eff 7/1;13)
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee:
Suppl. P(' Fee
PME Plan Check:
$0.00
Permit Fee:
Suj:)p/. Insp Fee
PME Unit Fee:
$25.00
PME Permit Fee:
$48.00
rx,,,!,nction Tax:T7
Administrative Fee: (ADMIN
$45.00
Work Without Permit? Yes (F) No
$0.00
,ldvancyed Planning Fees:
A
Travel Documentation Fee: ITRA VDOC
$48.00
Strong Motion Fee: IBSEISMICR
$0.90
Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC
$1.00
SUBTOTALS:
$167.90
$0.00 TOTAL FEE:
1 $167.90
Revised: 07/02/2015