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07080069 -77 7777777777� 7, CITY®F CUpERTINO BUILDING i„JiS10N PE121`�IIT PERMIT NO. BUILD��VFes LA PLAYA CT ANGSHUM7N SAHA __07080069 _ PERMIT ISSUE DATE ER'S NAME: ANGSHUMAN SAHA 21576 Lit PLA SANITARY NO. CONTROL NO. PONE: BUILDING PERMIT INFO ARCHITJrCT/ENGINEER: BLDG ELECT PLUMB MECH C� C7 O D ZLICENSED CONTRACTOR'S DECLARATION JOb Description o F. I hereby affirm that I-am licensed under provisions of Chapter 9(commencing Lv withSection 7000)ofDivision3ofthcBusiness and Professions Code,andmylicense is hallway bathroom upgrade - non structural no A in full force and effect. Z License Class Lic.# lighting no outlets p Date Contractor _ ARCHITECT-S DECLARATION I understand my plans shall be used as public records U l- Licensed Professional OWNER-BUILDER DECLARATION 1 hereby affirm that 1 am exempt from the Contractor's License Law for the o following reason.(Section 7031.5,Business and Professions Code:Any city or county �i which requires a permit to construct,alter,improve,demolish,or repair any structure N prior m is issuance,also requires the applicant for such permit to file a signed statementc Ft. Floor Area Valuation Y that he is licensed pursuant to the provisions Of the Contractor's License Law(Chapter 9 $2000 2 O 0 O o (commencing with Section 7000)of Division 3 of the Business and Professions Code)or '4 that he is exempt therefrom and the basis for the alleged exemption.Any violation of Occupancy Type Section 70315 by any applicant for a permit subjects the applicant to a civil penalty of 35623015 �Number not more than five hundred dollars($500). Q 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 Required Inspections and Professions Code:The Contractor's License Law does not apply to an owner of property who builds or improves thereon,and who does such work himself or through his own employees,provided that such improvements are not intended or offered for sale-11. however the building or improvement is sold within one year of completion,the owner- builder'will have the burden of proving that he did not build or improve for purpose of saleJ. �as owner of the property,am exclusively contracting with licensed contractors to rwnstmct the project(Sec.7044,Business and Professions Code:)The Contractors Li- cense Law does not apply to an owner of property who builds or improves thereon.and. who co(i'tlacts for such projects with a contractor(s)licensed pursuant to the contractors License Law. B&P C for I am exempt under ee B et" •Gtr Dale V d K R'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations: Q 1 ha+e and'will maintain a Certificate of Consent to self-insure for Workers Compen- sation,as provided for by Section 3700 of the Labor Code.for the performance of the work for which this permit is issued. Q I have and will maintain Workers Compensation Insurance,as required by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. My Workers Compensation Insurance carrier and Policy number are: Cartier. Policy No.: CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION 114SURANCE 14,Crhis section need not be completed if the permit is for one hundred dollars($1110) or less.) I certify that in the performance of the work fo hich -s permit's issued,1 shall not employ any personWD ttcr so as t to Workers'Compensation Laws of Californiaa A NOTICE TO APPr this 'ficatc of Exemption,you should becomt:subject to the Worker's Compensation provisions of the Labor Code,you must Z forthwith comply with such provisions or this permit shall be deemed revoked. O CONSTRUCTION LENDING AGENCY — I Hereby affirm that there is a construction lending agency for the performance of $>1 the work for which this permit is issued(Sec.3097,Civ.CJ a Q Lender's Name Z Lender's Address 0 1 certify that I have read this application and state that the above information is cored.I agree to comply with all city and county ordinances and state laws relating to U building conswction,and hereby authorize representatives of this city to enter upon the y W above-mentioned property for inspection purposes. y (We)agree to save,indemnify and keep harmless the City of Cupertino against y liabilities,judgments,costs and expenses which may in any way accrue against said City 2 in consequence of the granting of this permit. Date ►� APPLICANT UNDERSTANDS AND WILL COMPL7WITH ALL ON-PO Issued by - SOURCEREGUL O .Re-roofs Signature of A i t/ ontractor D Type Of Roof HAZARDOUS MATERIALS DISCLOSURE yP Will the applicant or future building occupantstorc or handle hazardous material 'efmiid by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety c,Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed. Q Ycs Io If a roof is installed without Will the applicant or future building occupant use equipment or devices which first obtaining an inspection,I agree to remove emit haatfrdous air contaminants as defined by the Bay Area Air Quality Management all new rr aterials for inspection. District? Q Yes rbwu 1 have read the hazardous materials requirements under Chapter 6.95 of the Califor- nia Htalth&Safety Code,Sections 25505,25533 and 25534.1 understand that if the building doci'not curtcntly It vc a tenant,that it is my responsibility ton fy the cupant of the Date rcqutrcmcu hie ustbemetpriortoissuanceoCaCcrtific of ry- Signature of Applicant U Q All roof coverings to be Class"B"or better Owner or �torixed agent Date CITY OF CUPERTINO 2 ITEMS OF 2 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN 35623015 . 00 DATE ISSUED. . . . . . 04/17/200 d RECEIPT #. . . . . . . . . : BS000004507 REFERENCE ID # 07080069 c/ SITE ADDRESS . . . . . : 21576 LA PLAYA CT SUBDIVISION `) CITY CUPERTINO IMPACT AREA . . . . . . OWNER ANGSHUMAN SAHA ADDRESS 21576 LA PLAYA CT CITY/STATE/ZIP . . . : CUFERTINO, CA 95014-4802 RECEIVED FROM . . . . : ANCUSHUNAN SAHA CONTRACTOR . . . . . . . : DAVID KIM LIC # 23862 COMPANY . . . . . . . . . . : DK CUSTOM BUILDER ADDRESS 4159 OLGA DR CITY/STATE/ZIP . . . : SAIS JOSE, CA 95117 TELEPHONE . . . . . . . . : (4C8) 497-9937 FEE ID UNIT QUANTITY FMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- -- -------- ---------- ----- 1BSEISMICR VALUATION 2, 000. 00 0.25 0. 00 0 .25 0. 00 1REMRESBAT SQ FEET 70. 00 275. 50 0. 00 275 .50 0. 00 BENERGY PERMIT FEE 1. 00 34 .86 34 . 86 0 .00 0. 00 BPERMFEE VALUATION 2, 000. 00 83 .16 83 . 16 0. 00 0. 00 BPFIXTURE UNITS 4 . 00 36 . 00 36 . 00 0 .00 0. 00 BREMVENFAN NO UNITS 1. 00 45 .39 45.39 0. 00 0. 00 BSEISMICRE VALUATION 2, 000. 00 0.50 0.50 0 .00 0. 00 PPERMITFEE FLAT RATE 1. 00 38.3738. 37 0. 00 0. 00 - -------- ---------- ---------- ---------- TOTAL PERMIT 514 . 03 238.28 275 .75 0.00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------- CREDIT - CREDIT CARD 275 .75 AMERICAN EXPRESS --------------- TOTAL RECEIPT 275.75 CUPEf\TINO � Assessor's Parcel Number: Name of owner. i,ra-ect address. J erson. - (`�'�0"#ft i� A t Phone. 40 9 9 2 3 Contact p Fax. Net square footage of lot. Ex istn.g Proposed Square footage: First floor: Second floor: _ Garage: TOTAL: Are there at least two 10 foot by 20 foot clear spaces inside the garage? � N Is privacy protection planting required for the project? On what floor(s)is work being done? Al Brief description of work. Cuk 1A CBC9(y N)2001 CFC 'j-1)2001 CMC �'- Code editions: 2001 2001 NE (Y -N) 2001 CPC EffdXtjgMAfY1f8&0Vz0 �J7 CUPERtINO CE WITFI THE CITY COPES AN11 ORDIPdAN 0 )ATF I L 'p �e rs Set O# s, ---._ ,�. Kept on 'aWhU1 tJ [Y7 same 13 Plan Review Process Work Book Page-8-Revised 8/22/05 L14 - -Tu Z 3C Ct L5 -------- clr� �� 6,J Z, OCL"j aV D ILI 17 5X Tj 0,U A A- �U C � a T(Aj- 00414 S� /04 't T' � kA /� . /� Q '' ` 1 �r��� OWNER-BUILDER VERIFICATION 1. (Check one) I or my immediate family (parent, spouse or child) will perform: A d j All the work authorized by this permit 1_-g," — A portion of the work C. — None of the work If B or C is checked,complete 2 or 3 below. ?. A state licensed contractor will be hired to do: A. — All of the work B. _ A portion of the woj,k (complete section below) Contractor Address/City Phone # State License # Type of work to be performed 3. _ I will utilize unlicensed person(s) other than my immediate family to perform all or portions of the authorized work. I understand that I may be an employer (see reverse side). A Certificate of Insurance covering workers' compensation must be on file at the City of Cupertino Building Department office. Person/Firm Address/City Phone Number Type of work to be erformed .......................................................................................... I declare under penalty of perjury that the at ove is true and correct. I have read and understand the Owner-Builder Information (reverse side). Date: Property Owner's Signature: Job Address: ,,��CA Permit# Any changes to the information provided on this form shall be submitted to the City of Cupertino Build Department. CITY OF CUPERTINO ADDITIOISIREMODEL CUPEkTINO PERMIT APPLICATION FORM APN # Date: -, L - _ �� U y �-77 �:)W ?- Building Address: Mailing Address (if different from building address): Owner's Name: Phone# Contractor: Phone#: Fax#: Contractor License#: Cupertino Business License#: Contact: Phone#: Fax#: Building Permit Info: Bldg. ❑ Elect. 0 Plumb. © Mech. E Hillside ❑ Job Description: Addition (adding sq footage): What is being remodeled? _ V J Remodel Includes Re-Roof. Yes ❑ No E�' If yes list number of squares Remodel Includes Structural: Yes [-] No E Square Footage: Addition: Porch: Deck: Garage: Detached Attached Remodel: Kitchen Bath Other Type of Construction (Usage Class): Occupancy Type: 1 A 11B ❑ 11, 111,V-A ❑ 11, 111, 1V V-B �J Valuation: Please check this box if the project is a second-sto i addition ❑ Please comp ete relevant portion of the Green Building Checklist& attach it to the application or if applicable, Green Building Points Achieved: include in plan set& the sheet index. ***For Office Use Only*** Over-the-Counter ❑ CITE' OF CUPERTINO IT APPLI( -ATION FO RM _ .10 TICJ0 Date: 14ailing Address (if diff rent from building address): Building Addres, ( �� 2 (S Phone# Y S— °) r� / f Owner's Name: ------ License#� �rntraCtO` Cupertino Business License#: Phone: —_--- Contact: Fax: --- O� - T73 - /4Ai Building Permit Info: / Mech Plumb L�' J, f,�ra e+Ve- tib\ Bldg Elec Job Description: omnmercia] ❑ Residential cSq.Ft.: Sq.Ft.Floor Are : anc Group: T O occupancy Cost of Project: Pase h ro ect is a lececk this box i the p j e of Construction: second-,story addition: ❑ Typ V31 Large Major ❑ roject Size: Standard ❑ Fee Grou Fee ID Fee Descri tion MECHANICAL Quantity Other A liances MECHANICAL BAppLOTHER Boiler<= 100,000 Btu MECHANICAL BBOILERI Boiler> 100K to 500K Btu BBOILER2 1M Btu MECHANICAL BBOILER3 :30iler> SOOK to MECHANICAL BBOILER4 F>oiler> 1M to 1.75 M Btu MECHANICAL BBOILERS Boiler> 1.75M Btu BUILDING BCONSTAX Construction Tax BUILDING d/Off/Comm/Quasi BUILDING BCONSTAX Con. Tax for BQ Zone BUILDING BCONSTAXBQ Hotel and Motel BUILDING BCONSTAXH Constax—Res'/Mobile BCONSTAXR 1000A ELECTRICAL Elec 600V <= ELECTRICAL BELEC 1000 Elec 600V > 1000A B <=200A ELECTRICAL ELEC1001 Elec Svcs 600V BUILDING BELEC200 Energy BUILDING BENERGY Energy Add Multi BENERGYADD BUILDING BINVESTIGA Investigation fee L 1 of 3