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11100212CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 18890 BARN14ART AVE I CONTRACTOR: I PERMIT NO: 11100212 I OWNER'S NAME: NIRAJ RAI & LORI AGRAWALI G�� "� PAI ILI' JU DATE ISSUED: 10/31/2011 I O wNER'S PHONE: 4087998605 LICENSED CONTRACTOR'S DECLARATION License License Class �- Lic. # Cf 3" 'T b j -J -%J -' a Contractor l %J ��W" R to 10 ' 3 �11(91 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. PHONE NO: BUILDING PERMIT INFO: BLDG ELECT r- PLUMB r— MECH �f— RESIDENTIAL COMMERCIAL JOB DESCRIPTION: INSTALL NEW SERVICE- RECEPTICALS SWITCHES & LIGHTS 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 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 Sq. Ft Floor Area: permit is issued. 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, costs, and expenses which may accrue against said City in consequence of the granting of this permit. Additionally, the applicant understands and will comply with all non -point source regulations per the Cupertino Municipal Code, Section 9.18. Signature OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: 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 construct the project (Sec.7044, Business & Professions Code). I hereby affirm under penalty of perjury one of the following three 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 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. 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 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. 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, and expenses which may accrue against said City in consequence of the .ng of this permit. Additionally, the applicant understands and will comply wmi all non -point source regulations per the Cupertino Municipal Code, Section 9.18. APN Number: 37533011.00 Valuation: $3000 Occupancy Type: PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTION. Issued '- % ` Date: A 3/—tf 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. Signature of Applicant: Date: ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER HAZARDOUS MATERIALS DISCLOSURE I have read the hazardous materials requirements under Chapter 6.95 of the California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Section 25532(a) should I store or handle hazardous material. Additionally, should I use equipment or devices which emit hazardous air 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 Health & Safety Code, Sections 25505, 25533, and 25534. Ow4cr or ant noriz a nt Q te: CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of work's for which this permit is issued (Sec. 3097, Civ C.) Lender's Name Lender's ARCHITECT'S DECLARATION I understand my plans shall be used as public records. Signature Date I Licensed Professional CUPERTINO GENERAL PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) T77-3333 • building(@cuperting.org \V - I-oT 7 T MrAT!_ nnAF rRA NTC'AL ELECTRICAL 0 21 Z. ❑ MISCELL.ANEOUS MEP misc ME'PMIsc,4pp_2011.doc revised 06/21/11 PROJECT ADDRESS 1 C/ �O I L,. A� OWNER NAME x' / / V PHONE qo (c' E MAM STREET ADDRESS 6 CITY, STATE, ZIP U' FAX CONTACT NAME 1� rA P �� `, I� E-MAIL /b FAX SiT�ADDS �� CITY, STA ZIP Cg go OWNER ❑ OWNER-a=ER ❑ OWNER AGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME / LICENSELICENSE TYPE BUS. LIC # 'A b <.i -' i O COMPANY NAMF,� Jam_ (� Fo r G -I / I (fin (� r� E MP's FAX STREET ADDRESS cig CITY, STA G� rr,L� j9 V PHONE U - a , �' •., S k3-. ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS. L1C # COMPANY NAME' E-MAIL. FAX STREET ADDRESS CITY, STATE, ZIP PHONE JSE OF ❑ SFD or DUPLEX 1:3MULTI-FAMILY PROJECT W WILDLAND ❑ YES PROJECT IN ❑ YES ❑ IS THE BLDG AN ❑ YES IICHLER HOME? [3 NO BUII.DING: ❑ COMMERCIAL URBAN INTERFACE AREA ❑ NO FLOOD ZONE NO A DESCRIPTION OF WORK TOTAL VALUATION: 0o 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 proper4 owner's behalf. I have read this application and the information I have provided is correct�J 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 nstruc ' n. I authorize representatives of Cupertino to enter the above -identified property for inspection pu(poses. Signature of ApplicanttAgent, Date: V SUPPLEMENTAL R,;FORMA110N UIRSD OFFICE USE ONLY ❑ OVER-THE-COUNTER a ❑ EXPRESS x U W r ❑ STANDARD U ❑ LARGE ❑ MAJOR ME'PMIsc,4pp_2011.doc revised 06/21/11 CITY OF CUPERTINO I " ►J3�1 Ti'TF r CTTM A 7"'P — RITTT ,11IN DIVNION LAIADDRESS: FEE ID DATE: REVIEWED BY: BP FEES APN: BP#: `VALUATION: 1$3,000 °PERMIT TYPE: Electrical Permit PLAN CHECK TYPE: Alteration / Addition / Repair PRIMARY SFD or Duplex USE: p PME Plan Check: PENTAMATION 1 REAP2 PERMIT TYPE: WORK 50 SCOPE $134 APPLIANCE / EQUIP TYPE FEE ID QTY UNITS BP FEES Services 1 ERT<200 100 Amps $44 PME Plan Check: Recep/Switch/Outlets 1BRE _ 50 # $134 Fixtures, Lighting f i 15 # $65 PME Permit Fee: $44.00 TOTALS: $41.00 $243.00 $0.00 Elec. Plan Check 10.0 1 hrs $0.00 Elec. Permit Fee: IEPERMIT Other Elec. Insp.0.0 hrs $44.00 NOTE: This estimate does not include fees due to other Departments (i.e. t ianning, ruouc rrorKs, r[re, aanerarynewer ei/s/ricy ,3cnvu/ FEE ITEMS (Pee Resolution 11-053 Eff T1,11) FEE QTY/FEE MISC ITEMS PME Plan Check: $0.00 PME Unit Fee: $243.00 PME Permit Fee: $44.00 Administrative Fee: IADMIN $41.00 Work Without Permit? 0 Yes (;D No $0.00 Travel Documentation Fee: ITRA VDOC $44.00 Strong Motion Fee: 1BSEISMICR $0.50 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $1.00 SUBTOTALS: $373.50 $0.00 TOTAL FEE: $373.50 Revised: 10/01/2011 8 ITEMS OF 8 CITY OF CUPERTINO PERMIT RECEIPT Sec: Twp: Rng: Sub: Blk: Lot: APN ........: 37533011.00 DATE ISSUED.......: 10/31/2011 RECEIPT #......... BS000015190 REFERENCE ID # ...: 11100212 SITE ADDRESS 18890 BARNHART AVE SUBDIVISION ...... CITY CUPERTINO IMPACT AREA ...... OPERATOR: patg COPY # : 1 OWNER NIRAJ RAI & LORI AGRAWAL ADDRESS 18890 BARNHART AVE CITY/STATE/ZIP ...: CUPERTINO, CA 95014-3602 RECEIVED FROM ....: TWISTED PAIR ELECTR CONTRACTOR TBD - TO BE DETERMINED LIC # 00096 COMPANY TBD - TO BE DETERMINED ADDRESS .......... CITY/STATE/ZIP ...: TELEPHONE ........ FEE ID UNIT QUANTITY AMOUNT PD -TO -DT THIS REC ---------- - NEW BAL ---------- lADMIN ------------- HOURS ---------- 1.00 ---------- 41.00 ---------- 0.00 41.00 0.00 1BCBSC VALUATION 3,000.00 1.00 0.00 1.00 0.00 1BREMFIXT NO. FIXTURES 15.00 65.00 0.00 65.00 0.00 1BREMRECEP NO. OUTLETS 50.00 134.00 0.00 134.00 0.00 1BSEISMICR VALUATION 3,000.00 0.50 0.00 0.50 0.00 1EPERMITFE FLAT RATE 1.00 44.00 0.00 44.00 0.00 1ERT<200 UNITS 1.00 44.00 0.00 44.00 0.00 1TRAVDOC FLAT RATE 1.00 44.00 0.00 44.00 ---------- 0.00 ---------- TOTAL PERMIT ---------- 373.50 ---------- 0.00 373.50 0.00 METHOD OF PAYMENT ----------------- CHECK TOTAL RECEIPT : AMOUNT --------------- 373.50 --------------- 373.50 VOICE ID DESCRIPTION -------- ---------------------------- 103 UFER 505 FINAL ELECTRICAL REFERENCE NUMBER -------------------- #1038 VOICE ID DESCRIPTION -------- ---------------------------- 304 ROUGH ELECTRICAL