11110172 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10134 S TANTAU AVE CONTRACTOR:RAMAN PERMIT NO: 11110172
MUMMIDIVARAPU
OWNER'S NAME: RAMAN MUMMIDIVARAPU 10134 S TANTAU AVE DATE ISSUED: 11/30/2011
OM&ER'S PHONE: 4087258925 CUPERTINO,CA 95014 PHONE NO:
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT rPLUMB r
License Class Lie,N
MECH r RESIDENTIAL r COMMERCIAL r
Contractor Date
1 hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:REMOVE&REPLACE 650SQF-r OF SHEETROCK,REPLACE
(commencing with Section 7000)of Division 3 of the Business&Professions 20
Code and that my license is in full force and effect. EXISTING CANNED LIGHTS,ADD NEW INSULATION
1 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: Valuation:$8000
permit is issued.
APPLICANT CERTIFICATION APN Number:37507038.00 Occupancy Type:
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 PERMIT EXPIRES IF WORK IS NOT STARTED
indemnify and keep harmless the City of Cupertino against onseiuenceof the WITHIN 0 AYS OF PERMIT ISSUANCE OR
costs,and expenses which may accrue against said City in consequence of the
granting of this permit. Additionally,the applicant understands and will comply 180 DA M L ST CALLED INSPECTION.
Aj �
11
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18.
Issued by: 4/ Date:
Signature Date
OWNER-BUILDER DECLARATION
RE-ROOFS:
1 hereby affirm that I am exempt from the Contractor's License Law for one of All roofs shall be inspected prior to any roofing material being installed.If a roof is
the following two reasons: installed without first obtaining an inspection,I agree to remove all new materials for
1,as owner of the property,or my employees with wages as their sole compensation, inspection,
will do the work,and the structure is not intended or offered for sale(Sec.7044,
Business&Professions Code) Signature of Applicant: Date:
I,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business&Professions Code). ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
1 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 HAZARDOUS MATERIALS DISCLOSURE
Compensation,as provided for by Section 3700 of the Labor Code,for the I have read the hazardous materials requirements under Chapter 6.95 of the
performance of the work for which this permit is issued. California Health&Safety Code,Sections 25505,25533,and 25534. 1 will maintain
I have and will maintain Worker's Compensation Insurance,as provided for by compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
Section 3700 of the Labor Code,for the performance of the work for which this Safety Code,Section 25532(x)should 1 store or handle hazardous material.
Additionally,should I use equipment or devices which emit hazardous air
permit is issued. contaminants as defined by the Bay Area Air Quality Management District 1 will
I certify that in the performance of the work for which this permit is issued,l shall maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
not employ any person in any manner so as to become subject to the Worker's Health&Safety Code,Sections 25505,25533,and 25534.
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 Own ti•oulhorize gent:
forthwith comply with such provisions or this permit shall be deemed revoked. Date:
APPLICANT CERTIFICATION CONSTRUCTION LENDING AGENCY
I certify that I have read this application and state that the above information is I hereby affirm that there is a construction lending agency for the performance of work's
correct.I agree to comply with all city and county ordinances and state laws relating for which this permit is issued(Sec.3097,Civ C.)
to building construction,and hereby authorize representatives of this city to enter Lender's Name
upon the above mentioned property for inspection purposes.(We)agree to save
indemnify and keep harmless the City of Cupertino against liabilities,judgments, Lender's Address
ciftnd expenses which may accrue against said City in consequence of the
g of this permit.Additionally,the applicant understands and will comply ARCHITECT'S DECLARATION
with all non-p ' source regulations per the Cupertino Municipal Code,Section
9.18. �^, 1 understand my plans shall be used as public records.
Signature I Date �� I Licensed Professional
CITY OF CUPERTINO
• 3 ITEMS OF 3 - PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 37507038.00
DATE ISSUED. . . . . . . : 11/30/2011
RECEIPT #. . . . . . . . . : BS000015437
REFERENCE ID # . . . : 11110172
SITE ADDRESS . . . . . : 10134 S TANTAU AVE
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : RAMAN MUMMIDIVARAPU
ADDRESS . . . . . . . . . . : 10134 S TANTAU AVE
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
RECEIVED FROM . . . . : RAMAN MUMMIDAVARAPU
CONTRACTOR . . . . . . . : LIC # *OWNER*
COMPANY . . . . . . . . . . : RAMAN MUMMIDIVARAPU
ADDRESS . . . . . . . . . . : 10134 S TANTAU AVE
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
TELEPHONE . . . . . . . . :
• FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
1BCBSC VALUATION 8, 000 . 00 1.00 0. 00 1.00 0. 00
1BSEISMICR VALUATION 8, 000 .00 0. 80 0. 00 0.80 0. 00
1REMRESOTH SQ FEET 650 .00 522 . 00 0.00 522 . 00 0. 00
------ ---------- ---------- ----------
TOTAL PERMIT 523 .80 0.00 523 .80 0. 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CREDIT CARD 523 .80 VISA
---------------
TOTAL RECEIPT 523.80
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255
• CUPERTINO (408)777-3228 •FAX(408)777-3333• buildingecuoertino.oro
❑NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION/TI ❑ REVISION/DEFERRED ORIGINAL PERMIT#
PROJECT ADDRESS 10 1APN#
OWNER NAME 4 ! _ I PHONE al by q�.—p ^{ E I (�
SIAEkT AD S a�/` . STA IIP
��' �( FAX
CONTACT NAME PHONE 7L 1 �
STREET ADDRESS CRY,STATE, ZIP FAX
16 75m- WNER-BUILDER ❑ OWNER AGENT ❑ CONTRACrOR ❑CONTRACTOR AGENT ❑ ARCHnECr ❑ENGINEER ❑ DEVELOPER ❑ TENANT
ONTRACTOR NAW LICENSE NUMBER LICENSE 7YPB Bus.LIC#
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,21P PHONE
ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC#
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,IIP PHONE
DESCRIPTION OF WORK
c Uti4
0V'j— reoV--�
EUISTING USE PROPOSED USE CONSTR.NPE OSTOR1BS
L- U � v u USE TYPE OCC. SQ.FT. VALUATION(S)
NEW AREA A�-1�C G^o DEMO
6C� NETREA(J
BATHROOMI KITCHEN OTHER
REIODELAREA REMODELAREA REMODEL AREA
PORCH AREA DECK AREA TOTALDEDUPORCHAREA I GARAGE AREA: DETACH
ATTACH
#DGUNrS: IS A SECOND UNIT FS YSECOND STORY YES
BRING ADDED? 0 ADDITION? 0
PRE-APMrATION ❑YES LF YES,PROVIDE COPY OF IS THE BLDG AN ❑vES RECEIVED BY: TOTAL VAL ATION:
PLANNINGAPPL# ONO PLANNING APPROVAL LETTER EICHLER BOMB? ClNO
By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on the prppetty owner's behalf. I have read this
application and the information I have provided is correct I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws mlating 'Iding cons a orize representatives of Cupertino to enter the above-identified property for inspection purposes.
Signature of ApplicanVAgrnC Daze:
SUPPLEMENTAL ORMATION REQUIRED PI.ANCHECKTYPE ROUTING SLIP
New SFD or Multifamily dwellings: Apply for demolition permit for ❑ OVER THE"OUNTER ❑ BUILDING PLAN REVtEW
existing building(s). Demolition permit is required prior to issuance of building
permit for new building. ❑ EXPRESS ❑ PLANNING PLAN REVIEW
Cormmercial Bldgs: Provide a completed Hazardous Materials Disclosure ❑ STANDARD ❑ PUBLIC WORICS
form if any Hazardous Materials are being used as part of this project ❑ LARGE ❑ Fina DEPT
Copy of Planning Approval Letter or Meeting with Planning prior to C1 MAJOR ❑ sANrrARY SEWFA DLSTH1Cf
bmittal of Building Permit application.
❑ ENVmommENTAL HEALTH
B/dgApp IOl1.doc revised 06121111
CITY OF CUPERTINO
FEE ESTIMATOR-BUILDING DIVISION
• itsADDRESS: 10134 s.tantau ave DATE: 11/30/2011 REVIEWED BY: building
APN: r0� —T—— Q BP#: "VALUATION: $8,000
*PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration /Repair
PRIMARY SFD or Du lex 2nd Unit? •Yes No PENTAMATION 1R3SFDREM
USE: p OTC? OYes (E)No PERMIT TYPE:
WORK remove and replace 650 sq ft of sheetrock replace 20 existing canned lights, add new insulation
SCOPE
OCCUPANCY TYPE: TYPE OF FLR AREA
CONSTR. s.f. PC FEES PC FEE ID BP FEES BP FEE ID
R-3(Custom) II-B,III-B,IV,V-B 0 $0.00 $0.00
TOTALS: 0 $0.00 $0.00
MECH, HOURLY ' 0 Yes O No PLUMB, HOURLY O Yes E) No ELEC, HOURLY O'Yes (E)No
h1e,•A, P''lou c:ha,^k P'1wuL_ 1'Irn C'hrok lilen. Ptnn C'hscl-
:Meeh, Perma Fee: Plunilr.Permit Fee: Fit:. Pernair Fee:
o"ho Vern.Lnsp. 08j"r 11hon;Lup, ofho Elcu. Lisp.
Mock Insp. Ince: Plumb. tnsp. I I Eden. Inep. Fee:
NOTE: This estimate does not include fees due to other Departments(Le.Planning,Public Works, Fire,Sanitary Sewer District,School
District etc.). These fees are based on the prelloina in ormation available and are oily an estimate. Contact the Dept for addn'l Into.
FEE ITEMS (Ree Resolution 11-053 E' . 7/Uf11 FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 650 s.f Remodel,Other
Suppl. PC Fee: (E) Reg. O OT F0,0Thrs $0.00 $522.001 IREMRESOTN
PME Plan Check: $0.00
Permit Fee: $0.00
Suppl. Insp. Fee-.0 Reg. O OT F0,0 hrs $0.00
PME Unit Fee: $0.00
PME Permit Fee: $0.00
C'on,struction Tax1717
Administratin•e Fee. O
Work Without Permit? O Yes 0 No $0.00 0
Advanced Planning Fee: $0.00 Select allon-Residential
Travel Documentation Fees: Building or Structure O
Strong Motion Fee: IBSEISM/CR $0.80 Select an Administrative Item
• Bldg Stds Commission Fee: IBCBSC $1.00
SUBTOTALS: 1 $1.80 $522.00 TOTAL FEE: $523.80
Revised: 10/01/2011
OWNER-BUILDER DISCLOSURE FORM
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
• 103DO TORRE AVENUE•CUPERTINO, CA 95014-3255
CUPERTINO (408)777-3228 - FAX (408)777-3333• buildinana cuoertino.oro
Dear Property Owner(s):
An application for a building permit has been submitted in your name listing yourself as the builder of the property
improvements specified at:
SITEADI E S j' j - APN BP#
O ER NAME �'O-^-', �j'V��_ OWNER ADDRESS loll F - �-
DESCRIPTION OF WORK: v:
We are providing you with an Owner-Builder Acknowledgment and Information Verification Form to make you aware of
your responsibilities and possible risk you may incur by having this permit issued in your name as the Owner-Builder. We
will not issue a building permit until you have read, initialed your understanding of each provision, signed, and
returned this form to us at our official address indicated. An agent of the owner cannot execute this notice unless
you, the property owner, obtain the prior approval of the permitting authority.
OWNER'S ACKNOWLEDGMENT AND VERIFICATION OF INFORMATION
(DIRECTIONS:Please read and initial each statement below to signify you understand or verify this information.)
I understand a frequent practice of unlicensed persons is to have the property owner obtain an"Owner-
lder" building permit that erroneously implies that the property owner is providing his or her own labor and material
• per orally. I, as an Owner-Builder, may be held liable and subject to serious financial risk for any injuries sustained by
an unlicensed person and his or her employees while working on my property. My homeowner's insurance may not
provide coverage for those injuries. I am willfully acting as an Owner-Builder and am aware of the limits of my
insurance coverage for injuries to workers on my property.
i 2. I understand building permits are not required to be signed by property owners unless they are responsible for
the construction and are not hiring a licensed Contractor to assume this responsibility.
I understand as an"Owner-Builder" I am the responsible party of record on the permit. I understand that I may
if ect myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her
name instead of my own.
(�4. 1 understand Contractors are required by law to be licensed and bonded in California and to list their license
numbers on permits and contracts.
L5. I understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the
total value of my construction is at least five hundred dollars ($500), including labor and materials, I may be
Z7oons,iderad an "employer' under state and federal law.
6c. 1 understand if I am considered an "employer" under state and federal law, I must register with the state and
federal government,withhold payroll taxes, provide workers' compensation disability insurance, and contribute to
unemployment compensation for each "employee." I also understand my failure to abide by these laws may subject
me to serious financial risk.
. I understand under California Contractors' State License Law, an Owner-Builder who builds single-family
residential structures cannot legally build them with the intent to offer them for sale, unless all work is performed by
licensed subcontractors and the number of structures does not exceed four within any calendar year, or all of the work
performed under contract with a licensed general building Contractor.
• 8. 1 understand as an Owner-Builder if I sell the property for which this permit is issued, I may be held liable for
any financial or personal injuries sustained by any subsequent owner(s)that result from any latent construction
defects in the workmanship or materials.
OwnerBuilderFon?7 2010.doc revised 04/14/10
V
understand I may obtain more Information regarding my obligations as an "employer"from the Internal
Service, the United States Small Business Administration,the California Department of Benefit Payments,
and the California Division of Industrial Accidents. I also understand I may contact the California Contractors' State
License Board (CSLB) at 1-800-321-CSLB (2752) or www.cslb.ca.gov for more information about licensed
ontractors.
10. 1 am aware of and consent to an Owner-Builder building permit applied for in my name, and understand that I
a the party legally and financially responsible for proposed construction activity at the site address listed above.
V11. 1 agree that, as the party legally and financially responsible for this proposed construction activity, I will abide
y—all applicable laws and requirements that govern Owner-Builders as well as employers.
12. I agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the
formation I have provided on this form. Licensed contractors are regulated by laws designed to protect the public. If
you contract with someone who does not have a license, the Contractors' State License Board may be unable to
assist you with any financial loss you may sustain as a result of a complaint. Your only remedy against unlicensed
Contractors may be in civil court. It is also important for you to understand that if an unlicensed Contractor or
employee of that individual or firm is injured while working on your property,you may be held liable for damages. If
you obtain a permit as Owner-Builder and wish to hire Contractors, you will be responsible for verifying whether or not
those Contractors are properly licensed and the status of their workers'compensation insurance coverage.
CONSTRUCTION LENDING AGENCY
(DIRECTIONS: Please complete the following construction lending agency information.)
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.)
Lender Name: Lender Address:
Before a building permit can be issued, this form must be completed and signed by the property owner and
returned to the agency responsible for issuing the permit. Note:A copy of the property owner's driver's license,
form notarization, or other verification acceptable to the city may be required to he presented when the permit is issued
to verify the property owner's si na r
Property Owner's Signature: Date: 1
--------
----------- -----------------------------
(NOTE: The following Authorization Form is required to be completed by the property owner only when designating an
agent of the property owner to apply for a construction permit for the Owner-Builder).
AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF
Excluding the Notice to Property Owner, the execution of which I understand is my personal responsibility, I hereby
authorize the following person(s)to act as my agent(s)to apply for, sign, and file the documents necessary to obtain an
Owner-Builder Permit for my project.
Scope of Construction Project (or Description of Work):
Project Location or Address:
Name of Authorized Agent: Tel No
Address of Authorized Agent:
I declare under penalty of perjury that I am the property owner for the address listed above and I personally filled out the
above information and certify its accuracy. Note:A copy of the property owner's driver's license, form notarization, or other
verification acceptable to the city may be required to be presented when the permit is issued to verify the property owner's
signature.
• Property Owner's Signature: Date:
O�,?ierBuilderForm 1010.doc revised 04/14/10
Building Department
City Of Cupertino
10300 Torre Avenue
Cupertino, CA 95014-3255
•
Telephone:
U P E RT I N O Fax: 408-777-3333
CONTRACTOR / SUBCONTRACTOR LIST
JOB ADDRESS: PERMIT#
OWNER'S NAME: PHONE# 0 ��
GENERAL CONTRACTOR: BUSINESS LICENSE#
ADDRESS: CITY/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.
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following information:
&/ SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets & Millwork
Cement Finishing
Electrical
Excavation
ah 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 ��✓'>
w er/Contractor Signature Daie