04110112 .CITY,OFCUPERTINO - ' - rK E* -
Bun Dirvc Division•=' PERMIT C'TQI2 VOR IO
v .... . ..
M" .....
BUILDING ADDRESS: PERMIT N b 4 11 0 112
1081' NOVEMBE
OWNER'S NAME: - - - PERMIT ISSUE DAM
RAMACHANDRA SRINIVAS 4
' ONE:
SANITARY NO. ' - CONTROL NO.
ARCHITECDENGINEER: BUILDING PERMIT INFO
BLDG_ • ELECT-'
- �.1:PLUMB. MECH_
40z, LICENSED CONTRACTOR'S DECLARATION
(esu 1 hemby art..Nat 1 am licensed undo,provisions of Chapter 9(commencing .Job Description
with Section 700o)nfDivuion 3 of the Basin.and Profession.Code,and my li.rup is
So Pn mranrms,mdcffect. - MAIN WATER LINE - .... _- ...
2 Liccnac Claa Lic.M _
Deho Contractor
ARCHITECTS DECLARATION
ryayq� I undcmtand my plans¢hall ba used az public mcoms
to
O Licensed Pmfesaional _-
S OWNER-BUILDER DECLARATION .. ... _ _
1 knohy affirm that I am exempt from the Character's Licence Lew for the
00 following mama.(Section'7031.5,Business and Professions Code:Any city or county
x m which requires a pemtit to compact,alter,improve.demolish,or repair any auucwrc
prior to its anomeh,Sit.mghireatheappheanl for Such Permit to file a algnedsta@ment ' lU OOY
that he is licensed pursuant to the provisions of the Conuacmr's Licence Law(Charter 9 - SCI.Ft. Floor Area Valuation
yFp$ (commencing with Section 7000)of Division 3 ofthe Businessand Profcamm Code)or
3.. Nal he is exempt therefrom and Ne buss for rate alleged exemption.Any violation of '
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penally of
not mom Nan five hundred dollars($500).
C '- QCCUpanCy Typo
C]I,an owner of the property,or my emPloyces with wages u their=to compensation,
willd.dmwmk,andrheaWclure is not intenticdmo(tared forme(Sec.7044,Busiws Re U1Ted Inspections— s_,��••y- ...., '+c` '••v
and Professions Code The Contractor's License Law does no,apply m an owner of -.,a, .:t�.wp.1 o,.er,- w9property who Wilds or i mproves dommen,and who does such work himself or through his '
own employees,provided that Such improvements are not intended proffered forule.If.
' however,the Indicting or improvement i,mid within one year of completion,Ne owner-
builder will ban the burden of proving that he did not Wild or improve for purpose of
spit.). _ -
,tpµl 1,as owner of the propeny,am exclusively comuting with licensed contractors to
tonswct the project(Sec.7W.Business and Profeuions Code:)The Conummra Li-
cave Law does not apply to ao owner of property who Wilds or improves thereon,and
who contracts for such projecho with a commetor(s)licensed purausnt in the Conuaetoes
License Law.
❑I am exemexempt,under Sec. \ ,lB&P C fm Nis mason
P
Ow -, ate if I3 2aD
WORKER'SCOMPENSAnONDECAXRATION
1 hemby affirm under pemity of perjury one of the following declarations: - -
I have and will meinum.Cenifrcate of Consent to self-inure for Worker'.Camino-
aation,u provided for by Section 3700 of the Labor Code,for Ne performance of the .
work for which this permit is issued.
❑1 he.and will maintain Worker's Compensation Insurance,as required by Sccdorr
3700of Ne Labor Code.fortheperformueeofdmworkforwhich Nispermitisiuued.
My Workers Compensation Instance carrier and Policy number are:
Cartier: - Policy No.: _
CERTIFICATE OF EKEMPI70N FROM WORKERS'
COMPENSATION INSURANCE
(This section need not W completed Vito Permit is ferone hundred dollars($106)
or Inst.) -
1 century that in the performance of the work for which this permit is issued.I shall not
employ any person in any mannerm as to become subject to the Workeri Compemadon
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making Nu Certificate of Exemption.you should
become object to tW Workers Compensation provision,of Ne Labor Code,you must
.,0 mi
forthwith comply with Such provisions or this pert shall W deemed revoked.
Z tiCONSTRUCTION LENDING AGENCY
[—i 1 hereby affirm that them is a construction lending agency for the performance of
W> the work for which this Permit is issued(Sec.3097,Cih,C.)
Q Landers Name
] z Lenders Address
J Q i cenify Net T have mad this application and shote that the above Information is
P correct,1 agree to comply with all city and county eminences and ab¢laws relating to
C building consumption.and hereby authodm representatives of this city to enter upon the
g17 above-memored prepeny for inspection purposes
y (We)agree to save,indemnify and keep harmless the City of Cupertino against
hy liabilitlea,judgments,amts and expenses which may in any way accmh against aid City
U w7 in consequence of the gmming of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NQN-P Issued by: Dat
AP IC NT UNDERSTANDS
5.
Sir -.,. (a Re-roofs
,gallopure of ApplicanUContractor D m
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupo stere or Wou"hvudous material
$-it
defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
de.Soction 25532(x)? All roofs shall be inspected prior to any roofing material being installed.
❑Yrs 191N.Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
haysrdoua air cmposco pro u defined by the Bey Ama Air Quality Mamgcmcnr all new materials for inspection.
District?
❑Yes �Nu
I have mad the hu ardnus mucdals requirements under ChaPtcr6.95 of the Colifm.
nia Hcalth&Safety Cole,Sectiom25505,25533 and 75534,I understand thnifthe Wilding
does not currentlyhove a¢nano that it is my responsibility to modify the occupant of the
my ' mcnuwhichmustNmelprioruissummofaCcniBcau:of en Signature of Applicant Date
'M y. A j 01 All roof coverings to be Class"B"or better
mer ser...Wrimd agcns an, - - g
Community Development
t ,
{ti 10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
#UPEkTINO
Building Department
JOB ADDRESS: 1 u R 1 Q o V e 1-t/3 M UW E PERMIT #
C,OPEI2?iNo CA qSOIt(-
OWNER'SNAME: kkHACHAMDCA SQINI✓ks PHONE #
GENERAL CONTRACTOR: AAA P LO M fIr N C, FAX #
I am not using any subcontractors: R- = 11/1.712oo4
Signature Date
Please check applicable subcontractors and complete the following information:
SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets &Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring: Carpeting
Linoleum/ Wood
Glass / Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing AAA P t V H Q I f J Cs
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/Contractor Signature Date
CITY OF CUPERTINO
OREPIPE/SEWERS/MAIN SERVICE ` I
CUPERTINO PERMIT APPLICATION FORM
APN# /� 1 / c)Z Date:
Building Address: 109% NOVEM6 RIVE (-vPEP-TtNa G jg-o)
Owner's Name: kMAC"K)b (Zh 9P I 014S Phone# if C) D 2 3
Contractor: .AAA PLUMQwG Phone: License#:
Contact: Phone: Cupertino Business License#:
Building Permit Info:
Bldg ❑ Elect ❑ Plumb L�
Job Description; REI,I-Ace MAtQ wg7ER LINE To HJJS[ wtTH PPM PIPE .
E4STJW6 PiPC ,1S lFkKiNG
Residential Commercial ❑
Cost of Project:, 16 00. DU
?pp .i
licable Fee ID Fee Description Fee Group
PPERMITFEE Plumbing Permit Issuance PLUMBING
BPREPIPE Re i e of Fixtures PLUMBING
BPERMFEE Bldg. Permit Fees BUILDING
BPFIXTURE Mg. Fixture PLUMBING
BPWSVCS Main Water Service PLUMBING
BPSEWER Sewers PLUMBING
BPSEWAGE Sewage Disposal PLUMBING
BUSLIC Business License BUILDING
2, 77 L