05100087CITY OF CUPERTINO
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PERMIT"CTQBUILDING DIVISION
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BUILDING ADDRESS:
SENTHIL PALANISAMY
1E11MiTNO.05100087
ER'S NAME:
PERMIT ISSUE DATE
SENTHIL P
PHONE:
SANITARY NO. CONTROL NO.
ARCHITECTIENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Jb Description
OIp
1 hereby Affirm dust 1 Am licensed under previsions of Chapter 9 (commencing
with Section 76f o) or Div Wan 3 of Ne Business and Profeminm Code, Amt my license IA
mfull ercece
WATER HEATER
License Claus
e Class
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Data Conusemr
Contractor
ARCHITECTS DECLARATION
LLE
I understand my plans NAZI he used as public records
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Nov
Licensed Professional
OWNER-BUILDER DECLARATION
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1 hereby Affirm NAI 1 exempt from the Contractor's License Law for the
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following reason. (Section 703 1. six,. and Co
Cod,: Any city as county
m dommil
pmntt on emulrthe slue impmw, demmWh, nr
construct, sig any atroclum
t,
whish TAS
$450
n
Issuance, e A
priormits W.ree,rstrrcquims the Appawmfor mchpermittoeos I..(suumem
Pter9
Conuimmnd
(caths inemi
Sq. Ft. Floor Area
Sectinttollmpmvieioruofdft
(commencingwith Seelirmon nd)ofDivision3 Prerfsionic
Code)or
theBed
yyi�
�{;l
for u coeandon. Myons
thathe7 therefrom and the the Any of
ailegod esemant
i
i O Occupancy Type
to l lemon
7G31.5 by applicantranapeanutrvbjecu Nc APpllcanttaacivil penalty of
31.5 b per j
AnNm
An,... mart Nan Tice hundred dollars (SS(pk
D 1, an owner ofthe property, or my employees with wages an their rete wmpcandon,
Required Inspections
will do the work, nrtd Neatnetum I,= intended or offered for We (See. 7044, Business
and Prolastin. Cade: The Canuanors Liee.e Law don not apply N an owner of
properly who builds or Impmm thereon, and who doessuch work himself or through his
own employees. providrA that such improvsmerts use not inuodad ornlfe ed fersale IL
r
harem. the building or improvement is sold within aro yar ofec mPledon. Ne owner.
builder will haw the burden of proWng Nat he did not Wild or improse for purpose or
role.I
lei, u owner of do pmpony. Am reclusively surrounding with licensed contractors to
construct the Project (sec. 7044. Business am Prornsio. Code:) The, CoouAcme. U.
cense Law does aot apply in an owner of propeny.who builds or improm Berton, and
who contracts for such pmjeets with a eanusemus) licensed pursuant in the ConuetoM1
License Taw.
❑ I Am exempt under See , B k P C f. this reason
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er Data 11
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WORKERS COMPENSATION DECLARATION / —
I hereby a(fum under penalty or perjury one of the fallowing declarations:
❑ Ihaa cod will maintains Cenifiwseal Co.cntmself-insure for Workeh Cernpen•
nation, As provided for by Section 3700 or Me Labor Cade, far de performance of the
work fm which this permit is issued.
I have and will maintain Worhees Compensation IM1Wranee, as mgY1Rd by Section
3700 of the labor Code, for Ne performance order work for which this permit is landed.
My Workers Campensadan Insurance wrier and Policy number are:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(TbW scum .N not be compieud if de permit is fare= hundred dollars (1100)
or loss)
1 artily that in Na performance of the work for which this permit is issued. I Nail not
employ any pmmn in any mannerAu u m bamma Aubjcet m Ne Wmk,r i Compnomi
.
laws of Caiifamia Dam 11
Applicator �. a0T
NOTICETOAPPILTANT: II, affermakiifthisCerfiricate or,Eaemption, you should
become subject an de Worker's Compensation previsions of Ne Lmur Code. you mud
forthwith comply with such provisions or this permit,ball W decm oI rooked.
CONSTRUCTION LENDING AGENCY
1 hereby of rn Nat Nem is a construction lending agency for the Performance of
the work for which this permit is bui (Sec, 3097, Ch. C.)
Lender's Name
'
Lender's Address
I certify that I haw read this application and state that the short information Is
CMTTCL I agree in comply wit all city and county ordinances and sou laws relating to
building construction, and hereby Authorize mpresematim of this city to enter upon the
above-mendoned property f. Inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
liabilities Judgments, costs and expenses which may in my way acerae against mrd City
in consequence of Ne granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT
Issued by: Date
SOURCE REGULATIO
Re-roofs
Type of Roof
o1246
Stil of App lean DAte
HAZARDOUS MATERIALS DISCLOSURE
Will de applicant or future building occupanwtom or handle hnsrdous oriental
defined by the Cupertino Municipal Code. Chapter 9.12. and do Health and Safety
A. Section 233324)?
All be inspected to any roofing material being installed.
❑tire ON.
roofs shall prior
If a roof is installed without first obtaining an inspection, I agree to remove
Will the app! cam or future building occupant use equipment or devices which
emit hayardous air contaminants As defined by the Bay Area Air Quality Management
all new materials for inspection.
Diauict1
Dyes ON.
I have mad the hazardous materials requirements under Chapter 6.95 of Me Califor-
niaHealth d': Safety Cade, Seedau 25303, 23533 stood 25534.1 understand tot if de building
does not curmuy haw A to A 1, Net itis reaponsibillty m nnul'y to occupant of to
mquiremcnta which must Ipria ,luanw .of Cc
cenincam of Dec ,y.
Signature of Applicant Date
I G Direr
All roof coverings to be Class "B" or better
Ow
r ar.whorimd ag
• CITY OF CUPERTINO
Item 1 of 1 PERMIT RECEIPT
Sec: Twp: Rng: Sub: Blk: Lot:
APN ........: 36907010.00
DATE ISSUED.......: 10/17/2005
RECEIPT #.........: 31636
REFERENCE ID k ...: 05100087
SITE ADDRESS .....: 10221 VICKSBURG DR
SUBDIVISION .......
CITY .............: CUPERTINO
IMPACT AREA .......
OPERATOR: suem
COPY # : 2
OWNER ............: SENTHIL PALANISAMY
ADDRESS ..........:
CITY/STATE%ZIP ...: CUPERTINO CA,'CA 95014-3358
0
U
RECEIVED FROM ....:
SENTHIL PALANISAMY
'
CONTRACTOR .......:
LIC # *OWNER*
COMPANY ..........:
SENTHIL PALANISAMY
ADDRESS ..........:
CITY/STATE/ZIP
...:
CUPERTINO CA, CA 95014-3358
•
TELEPHONE ........:
FEE ID
----------
UNIT QUANTITY
AMOUNT PD -TO -DT
THIS REC
NEW BAL
-----------------------
BENERGY PERMIT FEE
1.00
---------- --------------------
34.86 0.00
----------
34.86
0.00
BPWHEATER PER
HEATER
1.00
10.79 0.00
10.79
0.00
PPERMITFEE FLAT RATE
1.00
38.37 0.00
38.37
0.00
TOTAL PERMIT :,
---------- ---------- ----------
84.02 0.00
----------
84.02
0.00
METHOD OF PAYMENT AMOUNT
-----------------
NUMBER
OTHER
------------
84.02
------------------
AMERICAN EXPRESS
TOTAL RECEIPT
84.02
VOICE ID
DESCRIPTION
VOICE ID
DESCRIPTION
502 FINAL
PLUMBING ENERGY
506 GAS TEST
507 FINAL
PLUMBING
0
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Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone (408) 777-3228
Fax (408) 777-3333
Building Department -
JOB ADDRESS:` / PERMIT #
!/ (j 0 S—/DOa 7
OWNER'S NAME: T(7 cC, F}L6✓✓l B✓rl PHONE #
GENERAL CONTRACTOR: rrr,.rn/I--Ie '9(111_ DAC,P FAX #
I am not using any subcontractors: _G GC/ /
Signature
Please check applicable subcontractors and complete the following information
O eK
Date'
Wil.
Owner/ Contracto ature
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
Wil.
Owner/ Contracto ature
�CUPERTINO
CITY OF CUPERTINO
WATER HEATER
PERMIT APPLICATION FORM
l �
APN #/ ,(J�� 6
Date: 1 O I 2 M 5-
Building Acdddress: 10.2.2 ) V/CKS 9WC-x De
N /
PPERMTTFEE
Owner's Name: Sc— rALl�r4,f,,y
Phone#: 4�-!./4 6-�
Contractor: CL4 / t�< 9 Ul L_ pffg_ Phone:
License #:
Contact:S� �/}1 L %� /�J Phone: 4�� jr� _zk Lt
Cupertino Business License #:
Building Permit Info: �/
BldgEl Elect F-1PlumbL�
Mech ❑
Job Description:
/
Residential Commercial ❑
Cost of Project:
Strapped On Platform Bonded
New Location ❑ Replacement GJ/
Qty. if
Applicable Fee ID
Fee Description
Fee Group
BPWHEATER
Water Heater / Vent
BUILDING
PPERMTTFEE
Plumbing Permit Issuance
PLUMBING
BENERGY
Energy
BUILDING
BUSLIC
Business License
BUILDING
•