04040081 I CITY OF CUPERTINO _
BUILDING DIVISION PERMIT 4;CONT, OR=INFORMATION::.
<. BU I LDING A DDRESS' _ BAY AREA REPIPES PERMIT NO 04040081
19984 WHEATON OR
OWNER'S NAME: PERMIT ISSUE DATE
SANKARAN RAMANATHAN AND 13HAGAV1861 ORANGE GROVE DR 04/14/2004
ONE: SANITARY NO. CONTROL NO.
(408) 371-5763
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDC ELECT PLUMB MECH
0 0 0 0
X00 LICENSED CONTRACTOR'S DECLARATION
rd U I hereby affirm that I am Iicetsed under pmv0lons of Chapter 9(commencing Job DCSCrIpt100
n ad ii with Sec"tion7�Kk))of Divi5ion3 arrive Business and Prufessinm Code.and my license is
in nur6Qybneerrea. REPIPE/WATER SERVICE/WATER HEATER
g? LiccnSe closs_�_'��Lick
E"O Dare� Cm_ ntrecmrRwfto
e q�Q ARCHIIELDECLA
y B �YSBtlersmnd my plans shall he used as public records
JyU
T G y Licensed Pmfcasional
i S OWNER-BUILDER DECLARATION
ii! 1 hereby affirm that 1 am exempt from the Contractors License Law for the
ZOO following reason.(Section 7031.5,Business and Professions Code:Any city or county
$ which requires a permit in construct,alter,improve,demolish,or repair any structure
_yam prior to its ismancc,also requves the applicant forsuch permit to file aligned statement
gY< that be in licensed puumnitatothe Provisions nIthe Commerce's Li...Law(Charter 9 Sq.Ft. Floor Area Valuation
y t-O (commencing wi th Sued..7")of Division Sof the Business and Professions Cnde)or
y
tat he is exempt therefrom and Ne basis for the alleged exemption.Any vinlatfun of
Section 7031.5 by any applicant for a permit subjects the applicant to a c ■1�p A c�3kfXI1 ih6e10 0 Occupancy Type
not mare man five hundred dollars($5W). ■ o !s'�LC P Y YP
01,as owner of the property,or my employees with wages as their,sole compensation, LE
LJ
do the work entl Ne structure is not intended or offered for sale(see luvia�B�gJttst�ir�j�r7ea�sQ Required Inspections
and Professions Code:The Convenor's License Law does nut apply to 1j'rd$Ir l` 0, C 2004 q p
property who builds or improves thernan,and who does such work himselforh hs o L
own employees,provitled mm such improvements are not inoentled or oReretl foraala.IL
however,the building or improvement is sold within one year ofcoPPletion,P LDING
builder will have the burden of provingthat he did not build or improve for -
Sale.).
❑1,as owner of the property,am exclusively contracting with licensed contractors w
construct the project(Sec.1044,Business and Professions Cade:)The Comraao's Li-
se taw does not apply to an owner of property who builds or improves thereon,and,
who contracts for such projects with a contracmr(s)licensed pursuant o the Cmdractori
License Law.
I am exempt under Sec. ,B&P C for this reason
Owner Data
^y`NWORKER'S COMPENSATION DECLARATION
j I hereby affirm under Penalty of perjury one of the following declarations:
I have and will maintain a Certificate of Consent to self-Insure for Worker's Co Tri
sation,as provided for by Section 3700 of the tabor Code,for the performance of the
work for which this permit is issued
1 have and will maintain Worker's Compensation Insurance,as mquired by Section
37M of the Labor Code,for the performance orme work for which this permit issued.
My Workc' CompTd'onl umnce carrier and Policy number art:
l�fA�l
CERTIFICATE OF EXEMPTIONFRA WO K S'
COMPENSATION INSURANCE
(Thissection decd not bccomphred if the Permit is for enc hundred dollars(5100)
to less.)
1 certify mat in the performance of the work far which this Permit is issued.I shall not
employ any person in any manner so as to become subject to the Workers'Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this Cedilicam of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you most .
.JO fvnhwi th comply with suchpmvlsions or this Permit shall he,deemed revoked.
Zt ti CONSTRUCTION LENDING AGENCY
[tiff I hereby affirm that mere is a eodnmNnd lending agency for the performano of
Ri> the work fur which this permit is issued(See.3097.Civ.C.)
UJ Q finder's Name
r7 z Lender's Address
U Q 1 certify that 1 have read this application and some the,the above habituation is
IL F. correct.l agree to comply with all city and county ordinances and state laws relating to
0 abovedgeotioned ion,and hereby mthonprposes. tivesofthisCity to enter upon the
W
above-mentioned for inspection an keep ea.
(WB)agree to save,indemnify and keep harmless the City of Cupertino against
Uz
liabil
ities,eor go
dcxpenspewhich may in any way accrue against said City
C)z A FP
his permit.
APAND WILL COMPLY WITH ALL NON-POINT Issued by: Dale
SO
Z Re-roofs
SigDare
HAZARDOUS MATERIALS DISCLOSURE Type of Roof.
Will the applicant or future building uecuper store or handle hawduus material
as refined by the Cupedi no Municipal Code,Chapter 9.12.and the Health and Safety
ode,Section 25532(.)1 DO All roofs shall be inspected prior to any roofing material being installed.
m Yes /011z
1Will the applicant or future building occupant use equipment m d.,I.ma which If a roof is installed without first obtaining an inspection,I agree to remove
it hateardoes air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
t istrict7 y
[3 Yea nt No
I have mad the hazardous materials requirements under Chapter 6.95 of the Califon
all Health A Safe,CWc, tions i5505.255JJ and 25534.1unrkmmntl that ifmc Wilding
dues n e ndy have nano,thm it is my responsibility m nod l' the tscopent df the
rc ra cu wh' m MmetPdurteissuanccofa rvhc¢o cu err. Signature of Applicant Date
L/ -s� r�u
oar n rcdpgent Date All roof coverings to be Class "B" or better
Community Development
aClOF
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
Fax(408)777-3333
�UPEI�TINO
Building Department
JOB ADDDRES PERMIT# of U v
OWNER'S NAM 25 - /P
GENERAL CONTRACTOR FAX #
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
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
r Contractor Signature Date
CITY OF CUPERTINO
REPIPE/SEWERS/MAIN SERVICE
CUP4ERTINO PERMIT APPLICATION FORM
APN# Dat
Building Address:
I q' l/
Own 's Name:
Q440 a, �IC� kCL�Q v� �f ?E7— )71P3
C tractor: Phone: icense#:
Co to Phone: Cupertino Business License#:
ah e
3-7i ,
Building Permit Info:
Bldg ❑ Elect ❑ Plumb
Job Description p / L/'
I t �1�i/lL /1 % GuQ ! �(r✓ick t
Residential Commercial ❑
Cost of Pr je
11�-00 0.170
Qty,if
Appeioble Fee ID Fee Description Fee Group
PPERMrrFEE Plumbing Permit Issuance PLUMBING
BPREPIPE Re i e of Fixtures PLUMBING
BPERMFEE Bldg. Permit Fees BUILDING .
BPFIXTURE Pbl . Fixture PLUMBING
BPWSVCS Main Water Service PLUMBING
BPSEWER Sewers PLUMBING
BPSEWAGE Sewage Disposal, PLUMBING
USL Business License BUILDING