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04060112CITY OF CUPERTINO "' r, r e '•a e �r `" .4-�+' w t•I - BUILDING DIVISION PERMIT 3.CONTBACTQRdINFoORMATION, BUILDING ADDRESS: SUMATHI NATESAN TN PERMI004I060112 i0 7 NER'S NAME: PERMIT ISSUE DATE SUMATHI NATESAN 10171 STERN ANIR n6/14 9QQ4 NE: SANITARY NO, CONTROL NO, ARCHITECT/ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH LICENSED CONTRACTOR'S DECLARATION I ion:hy Nat 1 licensed Chapter 9 (commencing lob Description �� af0nn am under provisions of of Division S of the Bnsinessand Professinm Code. and my license is withSectionfnec n und.i m rmlfomas react. REPLACE MAIN ELECT PANELDate tr License Class Contractor ARCHITECTS DECLARATION ' +� 1 understand my plena shall W used as public records •(�/ zoos Liccnud Professional OWNER-BUILDER DECLARATION� I hereby affirm Nn 1 am exempt from dte License LicenLaw for the X following mann. (Section WO L5, Business and Pmf"Ohn, Calc: Any city or county ®� which requires a permit to mnnrocL alter, impmw, demolish. at repair any structure prior n its issuance. also requires the applicant foruch permit m file a signed statement that he is licensed pursuant to the previsions of dre Commcmr's License law(Chaftn" _ Sq. Ft. Floor Area Valu hon (commaming with Section 7") of Division 3 of the Business and Professions Code) or that he Is exempt therefrom and the, basis for the alleged gumption. Any vloladon of Section 7031.5 by arty applicant fora Permit subjects the applicant to a civil penalty of '7?�N]I'Q1firA3er0 () Occupancy Type more Nan five hundred dollars (5500). Luowmrofthe Pro y-. a my employees with wages u their sole compensatlon, - II do the .,k, and Ne structure is not intended oraRem4 tarsale (See. 7044, Business and Professions Code: The Comrutors License law does ant apply to an owner of Required Inspections progeny who builds mire prows dtercon, end who does s uch work himsel f or through his own employees. provided that such improvements arenot intended mnRercd for ole. If. however, the building or improvement Is sold imin ane year of completion, the owner- hullder will ban Jte burden of proving than he did not build or Improve for purpose of ole.). WIes owner of me property am exclusively conmating with licensed conmu m m . o wet the project (Sec. 70x4. Business and Professions Code:) The Conmcmh Li- cense law docs not apply in an owner of lumpeny who builds or improves Neeson, and who commode for such projects with a convacmrfU licensed pursuant to the Contractors License Law. x ❑lam rept underSe�py-� B h P C for Nis mason owner Data WORKER'S COMPENSATION DECLARATION I hereby affirm under Penalty of perjury one of Ne following declarations: 1 haw and will maintain a Cenifteme of Content to self-insum for WorkehCompcn- ntlon, u provided for by Section 3700 of me labor Code, for the performance of the wok for which this permit is issued. ❑ 1 haw and will maintain Workers Compensation Insurance, as required by Secuan 37W of Ne labor Cade, for me performance of the work fm which Nis permit is issued. , My Workers Compensadon Insurance artier end Policy numbef sm: Cartier. Policy No.: CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (TWA auction=ed not hecompleted lithe Permit is for one hundred dollars (5100) nr less) I ecnify Not in me performance of she work for which this permit is burned, I shell not employanypersur. any manners umb, sohjeeu showaro, Compcnsadon fl Laws of C I'f a APPliesnt — NOTICE TO APPLICANT:If. after making this Ccnificam of Exemption, you should become subject m du Workers Compensation provisions of then labor Code, you must foMwim comply with such Novisinna or this permit shall IK deemed revoked. CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the Performance of the work for which this permit Is issued (Sec. 3097, Civ. C.) (antlers Name Lenders Address 1 mnify that 1 have read this application and mute that me above information is cortecL I qua to comply with all city and county ordinances and sum laws uI.dng to building conhroction, and hereby aumodu mprrxmniveS climb city to enmr upon Ne shove-mentionedpurposes. propony for Inspectioneexpenses (We) agree to taw, indemnify and keep harmless du City of Cuportom against dgm and osteous which they in any way attme against said City fume in wide; Of the in conuquermc of the granting of This permit. APPLICAAANNNTTT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date SOURfrP GULATION f� l\— Re-roofs Type of Roof /_ rf "•- Signamm ofApphcanV onuumr Date HAZARDOUS MATERIALS DISCLOSURE Will the applicant or future Wilding occupant store or handle haasrdous material As defined by the Cupertino Municipal Cade. Chapter 9.12, and the Health and Safety Code, Section 25532(a)? ❑ Yu ❑ N. All roofs shall be inspected prior to any roofing material being installed. Will fuwm If a roof is installed without first obtaining an inspection, I agree to remove the applicant or building mculoot use equipment or devices which not horeNous air contaminants as Jcfned by the Bay Are. Air Quality Management all new materials for inspection. District? ❑Yca ON. 1 have read the hvarmms memorials requirements underChapno695aforeCalifor- hisHal" SafmyCode, Seeurns 25315, 25533 and 25534.1 underhand Nu if Ne Wilding doornmcurremlymarcaurect,Netitumyruin ihiitY mnoulyounecupantnrom mquirymgnts which cur W et 'to its... C ficloc or Occupancy. Signature of Applicant Date t -� All roof coverings to be Class "B" or better g caner or authorircd agent Date CITY OF �UPEkTINO Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone (408) 777-3228 Fax (408) 777-3333 Building Department JOB ADDRESS: OC 7 PERMIT # ®2 ' OWNER'S NAME: PHONE # GENERAL CONTRACTOR: FAX # I am not using any subcontractors: Signature Date Please check applicable subcontractors and complete the.followin information: 61 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 Roofing Septic Tank Sheet Metal Sheet Rock Tile V1� a L --a,,,. Owner/Contractor Signature Date CUPERTINO CITY OF CUPERTINO PERMIT APPLICATION FORM p l Z APN # ?7S — / / / O K Fee Group Date: ©/141 1 O (dif Building Address: 0 r n A Mailing Address (if erent from b ilding address): `fes l t` Owner's Name: v MECHANICAL �a.,A' Phone #: Contractor: BBOILER3 Boiler> 500K to 1M Btu MECHANICAL License #:j I , I r. �3 Contact: MECHANICAL Phone: — W-�o.-'7 7 Fax: Cupertino Business License#: Building Permit Info: Bldg ❑ Elect Plumb ❑ Mech ❑ Job Description: Residential Ind/Off/Comm/Quasi BUILDING Commercial ❑ Sq.Ft. Floor Area: BUILDING $/Sq.Ft.: Cost of Project: ,l LI � G� Ol Occupancy Group Type of Construction: Elec 600V <= 1000A op;{� Please check th box if the pro is a second-storyad ' IP�r'ect Size: Standard Laze ❑ Major ❑ ELECTRICAL Quantity Fee ID Fee Description Fee Group BAPPLOTHER Other Appliances MECHANICAL BBOILERI Boiler <= 100,000. Btu MECHANICAL BBOILER2 Boiler > 100K to 500K Btu MECHANICAL BBOILER3 Boiler> 500K to 1M Btu MECHANICAL BBOILER4 Boiler> 1M 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 <= 1000A ELECTRICAL BELEC1001 Elec 600V > 1000A ELECTRICAL BELEC200 Elec Svcs 600V <= 200A ELECTRICAL BENERGY Energy BUILDING BENERGYADD Energy Add Multi BUILDING BINVESTIGA Investigation fee BUILDING ] of 3 o CUPERTINO iWOF CITY OF CUPERTINO PERMIT APPLICATION FORM 2 of 3 Quantity Fee ID Fee Description Fee Group BMISCELL Miscellaneous Fee BUILDING BMITIGATC Comm. Housing Mit. Fee BUILDING BNUCOMME New Comm Electric ELECTRICAL BNUCOMMM New Comm Mechanical MECHANICAL BNUCOMMP New Comm Plumb PLUMBING BOVERTMffi Inspection Overtime BUILDING BPBACKFLOW Atmospheric Vacuum PLUMBING BPCESSPOOL Cesspool, PLUMBING BPERMFEE Bldg Permit Fees BUILDING BPFIXTURE Pblg Fixture PLUMBING BPGAS Gas Piping System Fee PLUMBING BPINTERCEP Ind Waste Interceptor PLUMBING BPLANCHK Plan Check Fee , BUILDING BPLANCKADD Plan Check Add Multi BUILDING BPLANCKREP Plan Check Repeat Fee BUILDING BPREPIPE Re i e Of Fixtures PLUMBING BPSEWAGE Sewage Disposal PLUMBING BPSEWER Sewers PLUMBING BPSPRINK Lawn S rinklerBackflo PLUMBING BPSTORM Storm/Rain Water PLUMBING BPTRAP Kitchen Trap PLUMBING BPVENT Alt of Drain & Vent PLUMBING BPWATER Install/Alter Water Pie PLUMBING BPWHEATER Water Heater/Vent PLUMBING BPWSVCS Main Water Service PLUMBING BREINSPECT Reinspection Fee BUILDING BREMACOVER A/C Unit > 10,000 cfrn MECHANICAL BREMAIRHAN A/C Units <=10,000 cfm MECHANICAL BREMAPPLI Appliance Install MECHANICAL BREM3USWAY Remodel Busways ELECTRICAL BREMFIXT Lighting Fixtures ELECTRICAL BREMFURN Relocation of Furnace MECHANICAL BREMFURNOV Relo Furnace > l OK btu MECHANICAL BREMHEAT Heater Installation MECHANICAL BREMINHOOD Installation of Hood MECHANICAL BREMMISC Misc Apparatus ELECTRICAL BREMNRAPP Rem Non -Res Appliance ELECTRICAL BREMPOLE Pole/Platform Fixture ELECTRICAL BREMPOWER Power Device/Apparatus ELECTRICAL BREMRECEPT Rc tl Switch & Outlets ELECTRICAL BREMRELOCA Relocation of Hood MECHANICAL Awk BREMREPALT Repair/Alter Heating MECHANICAL WE BREMRESAPP Remodel Res Appliance ELECTRICAL 2 of 3 CITY OF CUPERTINO CUPEkTINO PERMIT APPLICATION FORM Quantity Fee ID Fee Description Fee Group BREMSIGNAD Rmdl Sips Add Branch ELECTRICAL BREMSIGNS Remodel Signs, Marquee ELECTRICAL BREMTHEATR Theatrical Lighting Fix ELECTRICAL BREMVENFAN Vent Fan Single Duct MECHANICAL BREMVENSYS Ventilation Systems MECHANICAL BSCBLVD Scb Specific Plan BUILDING BSEISMICOM Seismic Commercial BUILDING BSEISMICRE Seismic Fee Res BUILDING BSPECIAL Special Insection BUILDING BSWIM Swimming Pool BUILDING BTEMP Temporary Power ELECTRICAL BTEMPPERM Temporary Bldg Permit BUILDING BTEMPSVCS Temp Dist Svcs ELECTRICAL BUSLIC Business License BUILDING ELECTRIC Electrical sq foot ELECTRICAL EPERMITFEE Elec Permit Issuance ELECTRICAL MPERMFEE Mechanicals . foot MECHANICAL MPERMITFEE Mech Permit Issuance MECHANICAL PPERMITFEE Plumbing Permit Issue PLUMBING PPLBG Plumbing Fee si 4G ZADDCHG Address Chane BUILDING 3 of 3