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12020006 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10394 COLBY AVE CONTRACTOR:SAND[UM PERMIT NO: 12020006 OWNER'S NAME: RAVAL.UDAYKUMAR R AND PARI_IL 4223 VERDIGRIS CIR DATE ISSUED:02/02/2012 OWNER'S PHONE: 408352,435 SAN JOSE,CA 95134 PHONE NO:(408)$94-9072 Rf LICENSED CONTRACTOR'S DECLARATION 'm. F.Q O BUILDING PERMIT INFO: BLDG = ELECT" PLUMB License Class C-2-0 Lic.# Bt8 0 �r. C MECH " RESIDENTIAL ' COMMERCIAL Contractor .J(/�`C�9�'�4nw. Date 2 Z ��Z I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:REPLACE DUCT WORK ONLY (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€nd 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 perruit is issued. Sq.Ft Floor Area: Valuation:$4500 1 have and will maintain p'orker'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:31629041.00 Occupancy Type: APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is correct.l agree to comply with all city and county ordinances and state laws relating PERMIT EXPIRES IF WORK IS NOT STARTED to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (,We)agree to save WITHIN 180 DAYS OF PERMIT ISSUANCE OR indemnify and keep harmless the City,of Cupertino against liabilities,judgments, 180 DAYS FROM LAST CALLED INSPECTION. costs,and expenses which may accrue against said City in consequence of the granting of this permit. Additionally,the applicant understutds and will comply with all non-point source regulations per the Cupertino Municipal Code,Section Issued b ' Date:, - 2--- t ..-- Signature � Date RE-ROOFS: ❑ OWNER-BUILDER DECLARATION 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 I hereby affirm that I am exempt from the Contractor's License Law for one of inspection. the following two reasons: I,as owner of the property,or my employees with wages as their sole compensation, Signature of Applicant: Date: 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 ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER construct the project(Sec.7044,Business&Professions Code). I hereby affirm under penalty of perjury one of the following three HAZARDOUS MATERIALS DISCLOSURE declarations: I have read the hazardous materials requirements under Chapter 6.95 of the I have and will maintain a Certificate of Consent to self-insure for Worker's California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain Compensa€ion,as provided for by Section 3700 of the Labor Code,for the compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health& performance of the work for which this perruit is issued. Safety Code,Section 25532(a)should I store or handle hazardous material. I have and will maintain p'orker's Compensation Insurance,as provided for by Additionally,should I use equipment or devices which emit hazardous air Section 3700 of the Labor Code,for the performance of the work for which this contaminants as defined by the Bay Area Air Quality Management District I will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the permit is issued. Health&Safety Code,Sections 25505,25533,and 25534. 1 certify that in the performance of Bre 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 Owrf4 authorized a nt: Compensation laws of California. [f after making this certificate of exemption,[ Date: k Z become subject to the Worker's Compensation provisions of the Labor Code,I must forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of work's APPLICANT CERTIFICATION for which this permit is issued(Sec.3097,Civ C.) I certify that I have read this application and state that the above information is Leader's Name 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 Lender's Address upon the above mentioned property for inspection purposes.(We)agree to save indemnify and keep harmless the City of Cupertino against liabilities,judgments, costs.and expenses which may accrue against said City in consequence of the ARCHITECT'S DECLARATION granting of this permit.Additionally,the applicant understands and will comply I understand my plans shall be used as public records. with all non-point source reg€€rations per the Cupertino Municipal Code,Section 9.18. Licensed Professional Signature Date Building Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014-3255 Telephone: 408-777-3228 C U P E RTI N O Fax: 408-777-3333 CONTRACTOR/ SUBCONTRACTOR LIST JOB ADDRESS14 PERMIT# Z— � OWNER'S NAME: PHONE# J? 2 S 3 GENERAL CONTRACTOR: �w` BUSINESS LICENSE# ADDRESS: rCITY/ZIPCODE: *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. Z/2- I am not using any subcontractors: Signature Date Please check applicable subcontractors and complete the following information: s/ 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 Metal Sheet Rock Tile Z lslzokZ Owner/Contractor Signature Date CITY OF CUPERTINO PERMIT RECEIPT OPERATOR: patg 6 ITEMS OF 6 COPY # Sec: Twp: Rng: Sub: Blk: Lot: APN . . . . . . . . 31629041.00 DATE ISSUED. . . . . . . : 02/02/2012 RECEIPT # . . . . . . . . . BS000015906 REFERENCE ID # . . . 12020006 SITE ADDRESS . . . . . 10394 COLBY AVE SUBDIVISION . . . . . . . CITY . . . . . . . . . . . . . : CUPERTINO IMPACT AREA . . . . . . . OWNER . . . . . . . . . . . . : RAVAL UDAYKUMAR R AND PARUL ADDRESS . . . . . . . . . . : 10394 COLBY AVE CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM . . . . .. YIU-HANG LEE CONTRACTOR . . . . . . . MICHAEL LEE LIC # 28867 COMPANY . . . . . . . . . . SANDIUM ADDRESS . . . . . . . . . . 4223 VERDIGRIS CIR CITY/STATE//ZIP . . . SAN JOSE, CA 95134 TELEPHONE . . . . . . . . (408) 894-9072 FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL- ---- ----- _ -------- ------------- ---------- ---------- ------0 .00 41 .00 0 .00 1ADMIN HOURS 1 .00 41.00 1 .00 0 .00 1BCBSC VALUATION 4, 500 -00 1 . 00 0.00 JBSEISMICR VALUATION 4, 500 -00 0 . 50 0. 00 0 .50 0 .00 1 .00 44 . 00 0 . 00 44 .00 0 .00 iMPERMITFE FLAT RATE 1 .00 65 . 00 0 .00 65 .00 0 .00 1MRRAA UINT I T S 1 .00 44 . 00 0 .00 44 .00 --------0 .00 1TRAVDOC FLAT RATE -- ---------- -- TOTAL PERMIT : 195 .50 0 .00 195 .50 0 .00 METHOD OF PAYMENT AMOUNT REFERENCE NU14BER ----------------- --------------- -------------------- CREDIT CARD 195 .50 VISA --------------- TOTAL RECEIPT 195. 50 VOICE ID DESCRIPTION VOICE ID ----DESCRIPTION--------- ----- -- ------------------ -- ------ -------- --- ----------- 505- FINAL ELECTRICAL - 507 FINAL PLUMBING 508 FINAL MECHA14ICAL CITY OF CUPERTINO FEE ESTIMATOR- BUILDING DIVISION - /"wx ADDRESS: 10394 Colby ave. DATE: 02/02/2012 REVIEWED BY: bobs. i APN: BP "VALUATION: $4,500 PERMIT TYPE: Mechanical Permit PLAN CHECK TYPE: Alteration /Addition/ Repair PRIMARY PENTA1tiIATION FURN/AC USE: SFD or Duplex PERMIT TYPE: WORK replace duct work only- SCOPE nl SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Heating System 1 MRRAA 1 # $65 TOTALS: $65'00 Nlech.Plan Check 0.0 hrs $0.00 Mech.Permit Fee: IMPERMIT Other Mech.Insp. OAhrs $44.00 h'QTE: This estimate does not include fees due to other Departments(i.e.Planning,Public Works,Fire,Sanitary Sewer District,School District,etc.). These Lees are based on the erelininart,information available and are only an estimate. Contact the Den or addn'l in o. FEE ITEMS t t FEE QTY/FEE MISC ITEMS PME Plan Check: $0.00 PME Unit Fee: $65.00 PME Permit Fee: $44.00 Administrative Fee: !ADMIN $41.00 Work Without permit? 0 Yes Q No $0.00 Travel Documentation Fee: ITRA VDOC $44.00 Str£W,;).r I46-I1" Fee : IBSEISMCR $0.50 Select an Administrative Item ��,r;i r;icr, Fe'— IBCBSC $1.00 SUBTOTALS: $195.501 $0.00 TOTAL FEE: $195.50 Revised: 1/19/2012 r ;;)C� L U C� C.P GENERAL PERMIT APPLICATION MEP COMMUNITY DEVELOPMENT DEPARTMENT-BUILDING DIVISION 10300 TORRE AVENUE-CUPERTINO, CA 95014-3255 LM (408)777-3228• FAX(408)777-3333- building(Dcupertino.org MISC CUPERTINO ❑PLUMBING OIv ECHANICAL ❑ELECTRICAL ❑(NaSCEL,LANEOUS PROJECT ADDRESS to 311 I f /� _i '�� V ` OWNER NAME l I ,1Y ,. y� PHONE 4S 35 Z 5[x.35 E-MAIL STREET ADDRESS CITY, STATE,ZIP FAX Sccr.� aQ 1 b CONTACT NAME PHONE E-MAIL. STREET ADDRESS CITE',STATE, ZIP FAX ❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT Ly CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT CONTRACTOR NAME . M LICENSE NUMBER (I 1 Q LICENSE WENNS�ECT'Y.1.P.E. BUS. LI C# COMPANY NAME EMAIL CSFAX DRESS ` Cm.STATE ZIP PHONE STREET AD �� ARCHITECTIENGINEER NAME LUI SE N MBER J J BUS.UC# COMPANY NAME' E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE USE OF SFD-DUPLEX ❑ MULTI-FAMILY PROJECT IN WILDLAND ❑ YES 7PROJEC—TIN ❑YES IS TIE BLDG AN ❑YFS BUILDING: ❑COMMERCIAL URBAN INTERFACE AREA ❑ NO ZONE ❑NO EICHLER HOME? ❑NO DESCRIPTION OF WORK DAC\UO57 �i VK w ``t C TOTAL VALUATION: DD RECEIVED BY: 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.,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 bu' g construe I authorize representatives of Cupertino to enter the above-identified property for inspection pulposes. Signature of Applicant/Agent:_ 2Date: z�7i f 20 SUPPLEMENTAL INFORMATION REQUIRED OFFICE USE ONLY I_T OVER-THE-COUNTER c ❑ EXPRESS Y U W ❑ STANDARD U ❑ LARGE e, ❑ MAJOR MEPMiscApp_2011.doc revised 06121111