04040065 (2) CITY OF CUPERTINO "aars, a
BUILDING DIVISION PERMI CONTaRACT' I�TNOtMAI1
INGADDRESS: MISSION DEVELOPMENT CORP PERMIT N004040065
1211 STAPF(')RT) DR
OWNER'S NAME: PERMIT ISSUE DATE
PALANIAPPAN KARVP2ANfEB= 4-1197 OSGOOD RD n4/ng/2004
PHONE: SANITARY NO. CONTROL NO.
(510) 657-4777
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MWH
3oa LICENSED CONTRACTOR'S DECLARATION ]Ob DeEClIpIIOn
I hereby affirm situ 1 em licensed unJc pmviaiou of Chapter Y(commencing
wlthsom��ppn7�� )of Divi.km3orZBassi end Profctsi endmyliccnscit
nfu1lfor� f`am 2 BATHRMS UPGRADE
55z ucenx c1eA — Lic.g
Dow -E
ARCHITECTS DECLARATION
I undminist
y plats shall W used As public records
J U
Licensed Professional
OWNER-BUILDER DECLARATION
0 f I Maso affirm on 1 em,Bumps from Ipr Conlnetah License Law for the
p o which ng tares a purnit t B13L5,Business And vat.de inns h,or Chile: ai city or county
$� which requires a peomit m ennsuud,eller,improve.demolish,or repair any structure
as prior to its issuance.also requires he applicant for such permit to Ela a signed suremcia
that he it licensed poroma m the provisions of tWComnh cmLicense Law(Chap¢r 9 Sq.Ft.Floor Area Valuation
$ (commencing with Section 70DO)of Division 3 nribc Business and Professions Code)or
that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicamfor a permit subjects the applicant o a civil penalty of 3@a2191Offi1er00 Occupancy Type
not mon than Eve hundred dollar($500).
❑1,As owner of the property,or my employees with wages u their sole compensation,
will do the work,and the structure Is not Intended or offered for sale(Sec.7099,Business
And.Professions Codc:The Contractor's License Law does not apply to an owner of Required Inspections
empeny who build&or improve themon,and who doeuuch work himself or through his
own employees,provided that such improvements Are not Intended or offered for ole.If. LVI
however.the have
the
b r improvement proving
that
he within et year of completion,the owned 1�Ice 1
.builder will have the burden of proving th+t he did net Wild or improve for purpose of
ule.).
L7Jl 1
1,as owner of the progeny.Am exclusively contracting with licensed comsxn Nto
construct the project(Sec.7094,Business And d Professions Code:)The Canuanmr's Li.
e PIhw does not apply to an owner of progeny who Wilds or improves demon,and
comncts for such projects with a comnctor(s)licensed pursuant to the COmmctob
nae Lew.
Am exempt under Sec. .B&P C far this reason
Own& Data—
WORKERS
ateWORKERS COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of Be,following dethomil ns:
❑1 have And will maintain aCcnificme of C.M nl m self-insure for Wrolme.Campen.
tour,As provided for by Section 37M of tW TAW,Code.for the performance of tie
work for which this permit Is issued.
❑I have and will maintain Worker's Compemadon Insurance,As reluind by Section
3700arthe boa Cnde.far Ne peRormance of the work for which Nit petrels is Issued.
My Work m 'Al" man sad Polic,�, Wrue:
Carrier. �&P- polity ., ��
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSU RANCE
(Thu section head not be cmnpleted If the permit is for one hundred dollars(5100)
or lass.)
1 anify Npt in the perrormatee or the work for which this permit u issued.I tlu11 not
employ any person in any manner an As N Wconne subject to We Workers'Compensation
Laws.[California.Data
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become..o.he the Worker's Compensation provisions of the LaWr Chile.your must
0 z tuMwith comply with such provisions our this permit shall be deemed evoked.
z CONSTRUCTION LENDING AGENCY
[-+ I hereby affirm that Nem its constauctinn lending agency for the Performance of
a IW work for which this perealt It Wood(Sec.3097,Cl,C.)
W Q Undeh Name
]z Lendera Addtus ,
U Q I certify dist 1 haw mead Nis application and&use Nat the thew information I.
Ile (~
correct.I Agree to comply with all city and county ordinances and site,laws Misting to
0 building construction,and hereby amhorire MpresenudWS of this city to enter upon the
W above-mentioned property for Inspection purposes
(We)agree to save,indemnify keep harmless the City Of Cupenino Against
ti rajl and liebilitie&.judgment,costs and expenses which may in any yamamc Against said City
(„)7 in cnnsegoe Ne grantin !this permit.
F� APPLIC ND ST AND WILL COM ITH ALL NON-POINT Issued by:9 Date
SOU GU 0 f
Re-roofs
mann ofAp Ica connector Oat
"OU
MATERIALS DISCLOSURE Type of Roof
WiII eAp lic+m°r Nom Wilding occulnm stare or handle hererdom material
as deli's..by the Cupertino Municipal Code,Chapter 9.13,and the Health and Safety
Code,Section 15533(57All roofs shall be inspected prior to any roofing material being installed.
C]Yet
Will the applicant or Room Wilding occupant use equipment or devices which 'If a roof is installed without first obtaining an inspection,I agree to remove
emit honrdnua sir contaminants As deflated by the Bay Area Air Quality Management all new s for inspection.
District7
❑Yes
I hove mist" rte mateai+h, encore n"umde Chapler6.95orthe Califon
hie Health&Safe ad. tions355115, 533 and 35534.1 unlernand thntiflAe building
does not curt have at"' y resplinslbitlty m audit,the occoPant of Ne
repo re ch d statnceollCeninesmofOc.mp ignatureofApplicant Date .
owner ra t arirnJegcn D All roof coverings to be Class"B" or better
Stu -�
ATY OF CUPERTINO
CUPERTFINo PERMIT APPLICATION FORM
APN# Z D Date:
Building Address: Mailing Address (if differfrif from bu' ding address):
All . -
0> er's Name: Phone#:
Co r ctor: License #:
o t: Phone;5,e-Lsy - ?7 Cupertino Business License#:
lrlc Fax: -Po -6 /
Building Permit Info:
Bl ❑ Elect ❑ Plumb ❑\ Mec
Job Description:
Residential 69&4ftv", Commercial ❑
Sq.Ft. Floor Area: $/Sq.Ft.:
ostofProject- i� Occupancy Group:
Type of Construction: Please check this box if the project is a
second-story addition: ❑
Quantity Fee ID Fee Description Fee Group
BAPPLOTHER Other Appliances MECHANICAL
BBLDGFEE Bldg Permits . foot BUILDING
BBOILERI Boiler<= 100,000 Btu MECHANICAL
BBOILER2 Boiler> I OOK to 500K Btu MECHANICAL
BBOILER3 Boiler> 500K to 1M Btu MECHANICAL
BBOILER4 Boiler> IM to 1.75 M Btu MECHANICAL
BBOILER5 Boiler> 1.75M Btu MECHANICAL
BCONSTAX Construction Tax BUILDING
BCONSTAX Ind/Off/Comm/Quasi BUILDING
BCONSTAXBQ Con. Tax for BQ Zone BUILDING
BCONSTAXH Hotel and Motel BUILDING
BCONSTAXR Constax-Resi/Mobile BUILDING
BELEC1000 Elec 600V<= IOOOA ELECTRICAL
BELEC1001 Elec 600V> 1000A ELECTRICAL
BELEC200 Elec Svcs 600V<=200A ELECTRICAL
BENERGY Energy BUILDING
BENERGYADD Energy Add Multi BUILDING
BINVESTIGA Investigation fee BUILDING
BMITIGATC Comm. Housing Mit. Fee BUILDING
1 of 3
�I
APPROVED
IN ACCO E WITH CITY OR
CUP R I ODE .0 t INC
DATE
SIGNED
This set of plans nd s zcifications MUST
De kept on the ' b a II times and i is un.,
lawful to make a changes or, alterations
on same withou written permission from
the building Dept., City of Cupertino, copy
The stampingof this plan and specifications . l�lSHALL NOT be held to permit of to be ar,
approval of the violation of any prowatm
of any City Ordinance of State Lew.
APR VED •
1004Jry
8 r��GF�EPPf R��O
gRlNjENr (E) 6068 SL. 09.
0
I
- I
(E)
BATH
.G.
(E1)�
S R
BE
DRM
BATH 050HALL -
S e P
7
-------------
Oso Oso
m
1 _ BEDROOM
#2 I BEDROOM #1
I
{ (E) 3040 (E) 3040