06030100 (2) CITY QF CUPERTINO + o .ar o¢ +/,t+mw'"x, r'r.� e" z z ;s'.
BUILDING DIVISION PERMIT sC`ON'$ 1.CTOR'I1VX'b "CI()1�
YC:>r. ,a,> Nee 3 �n:ikx"spa_u.kq we'ew w, '
BUILDING ADDRESS: - PERMIT NO.
11550 LAKE SPRING CT
OWNER'S NAME: FERMI T ISSUB DATE
I „ PRATIBHA SURYADEVARA 1000 N RAND RD, ##112 03/20/2006
tl NE: SANITARY NO. CONTROL NO.
1 (866) 293-3031
ARCHITECTIENGINEER: - BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
300 LICENSED CONTRACTOR'S DECLARATION O O
'�+ 1 hereby affum tan I am licensed under provisions of Chapter 9(commencing Job Description
with Section 70u0ofDIA.lon3afthe Business and Profesuions Cadgandm lieuheia
OF
irtuilroceaneerr S�f9p y REPLACE HOT WATER HEATER/50GAL GAS TALL 12 YR
Z License lou ConLic.tractor
�'
Dem ^ usemrumr � '
RCHf1ECTS DECLARATION O �D
I unMrsund my pons shall`E used upublic CLARA cord, L
5�yy��
y4p Licensed Prof.mmml
OWNER-BUILDER DECLARATION ���a2� L
1 hereby.III.that I em Gump,from the Contratmes Liwnsc Law for tan ra006 $500 5 O O
0 o following mamn.(Section 71131.5,Business and Pm(euions Code:Any city or county $
3$E., which acquires A Permit to Conswct,alar,imprnw.demolish,or mpnir my aweure
_Z'12 poor m its israumG,she requires to applicant for such Permit m file a signed summer,
< Net he isBcensed portentm the provisions of the Centimeter's LlceuC Law(Chapter 9 Sq.F a Valuation
?�5 (cam mencing with Section 7000)of Division 3 of the Business and Professions Code)or
s .. dot ba isleompt therefrom and da bub for the alleged cum pdon.Any violation of
Section 7031.5 by airy applicant for a Permit subjects due applicant to A civil Penalty of APN Nilin-lici Occupancy Type
.at¢ort Nen Ow hundred dollars($500). -
❑I,ssawnuofthepmpeny.mmyemployeuwithwguutmlrwlecomMMUon,
will do the work and the structure in no,intended u offered for sale(Sm.70/4,Business Required Inspections
and Prefeuwe nsion.Code:The Comounce,ce,License law don not apply to an Owner of q P
progeny who bui Ids or im prows Damon,and who doessuch wok himself m through his
own employer,pmvided thet such improvements art at intended oroffered loutish,IL
however.the building or Improvement is mid within one your of completion,the owner.
builder will have the burden of Proving that he did am build or improve for purpose of
sal.j.
Cj I.u Owner of the property,am eu]usively contracting with licensed mntnnors m
Consumer,he pan*[(Sec.7044,Burow and ProrraYans Code:)The Common',U.
come Law does not Apply m an owner of property who builds or improves thereon,and
who contracts for such project/with a contractor(s)licensed pursuant m to Contncmts
License LAW.
❑lam Gxemptunder Sec ,BlPC(ordlsmaen
Owner Dau
WORKERS COMPENSATION DECLARATION
I hereby alarm under penalty of perjury arc of the following declhatiou:
❑1hawandwillmalnuinaCe raamofConsentmul6Wumfar Workers Compere
nation,an provided for by Station 3700 of the labor Code.fm the perfumaam of the
work for which this prem,is issued.
❑1 ban and will maintain Worker's Compensation Imunnce,as required by Section
3700 of the labor Code.far the performance of the work far which this permit Is Issued.
My Workers Compensation Insurance cerise and Policy number are:
tinier. R \'fC�, Ponq Na.:C-v` C 4�42-164's/
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This Room Good not becomplemd ifthe Permit Is foram hundred dollars(5100)
or law.)
I comfy that in the performance of the work for which this pearl,Is head.I WWI not
employ any person in any mannerm at m become subject in the Workma Compamation
Laws of Califumia.Data
Applicant
NOTICE TO APPLICANT.If,afar making this Certificate of gumption,you should
become subject in the Worker's Compensation provisions of the Labor Code,you mum
.J ZO forthwith comply with such provisions in this permit wall be deemed revoked. -
Z vyN., CONSTRUCTION LENDING AGENCY
(+ I hereby atiim Out Nem is a contraction lending agency for the performance of
C> the work for which this permit is betted(Sec.3097.Civ.C.)
a0 Lcruhes Name ,
i1. z LUWer's Addem
U0 I Certify that I haw mad this application end mute that the above infomudon b
Uy P correct,l agree to comply with all city and county ordinances and same law relating in
O U building epnAtranian,and hemby authorize mprescnmiru crisis city m enter upon to
{17 abe-Ommiomd pmperty,for inspection purposes.
!F^+fy (We)agree to naw,indemnify and keep harmless,he City of Cupertino against
„y(A liabilities,judgmcnu.cash and expenses which may in any way sane.galm mid City
U 7 in consequence of the grating of this permlL
Fl APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
�t-�.9.�� 3 �-9 Re-roofs
Signature or AppliandCantracter Data
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or room building occupant store or handle haurdous memo.]
u deftmd by the Cupertino Municipal Code.Chapter 9.11,and the Health and Safety
Cade,Sudan 25531(a)? All roofs shall be inspected prior to any roofing material being installed.
❑Yea ONO
LWill the applicant or future building occupant arc equipment or devices which If a roof is installed without first obtaining an inspection,l agree to remove
t heufdous air conmminanu in dcflwd by the Bay Am,Air Quality Management all new materials for inspection.
District?
❑Yes %No
I haw mad the huardnusmucdabrequiremenh underChepar495ofthe Califon.
ria Hcalthl Safely Ccde,Sedma15505,15533 mW29534.1 undcrmand thuifthc building
dues ret currently hew•tenant,that It is my responsibility in ratify the occupant of the
mgalag, cots whkh ren,be met poormissu en of a Cenificam or occupancy. Signature Of Applicant Date
O, -3-240-OC, All roof coverings to be Class"B"or better
Owur or amhooud agent Dam
4 CITY OF CUPERTINO
4 of 5 PERMIT RECEIPT OPERATOR: suem
fK COPY # 3
Sec: Twp: Rng: Sub: Elk: Lot:
APN . . . . . . . . : 36654037.00
DATE ISSUED. . . . . . . : 03/20/2006
RECEIPT #. . . . . . . . . : 33636
REFERENCE ID # . . . : 06030100
SITE ADDRESS . . . . . : 11550 LAKE SPRING CT
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : PRATIBHA SURYADEVARA
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : CUPERTINO CA, CA 95014-5120
RECEIVED FROM . . . . : METRO MECHANICAL
CONTRACTOR . . . . . . . : PAUL HENDRIXSON LIC # 27607
COMPANY . . . . . . . . . . : METRO MECHANICAL INC
ADDRESS . . . . . . . . . . : 1000 N RAND RD, #112
CITY/STATE/ZIP . . . : WAUCONDA, IL 60084
TELEPHONE . . . . . . . . : (866) 293-3031
OEE 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
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
502 FINAL PLUMBING ENERGY 506 GAS TEST
507 FINAL PLUMBING
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
UPEkTINO
Building De artment
JOB ADDRESS: PERMIT#
5-50 Lct `nq Ci d
OWNER'S NAME: ,( ,C,. %,,XG .Qv PHONE # k0e Rq4p GS-RS-
GENERAL
omGENERAL CONTRACTOR: 1 1-�jp,vc4 FAX # (p P."I am not using any subcontractors:
� 3-20- 0�0.
Signature Date
Please check applicable subcontractors and complete the following information:
60 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 J,,r-sv ' Q 27 ,Q-1
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
3 --2oC951:1
Owner/Contractor Signature Date
CITY OF CUPERTINO
•'
WATER HEATER
CUP IkTINO {� PERMIT APPLICATION FORM
APN 3lD(O' ✓'i" Q�} Date:
Buildi g Address:
�.�
Owne 's e: Phone#: _
11 C�k.. U1 L Ck Ck Q' r , G,
Co tr ctor: License#:
r I pluol - n �- 1-�.i,n_F �sl��o(fl�s
Conta t: Cupe o Business License #:
��tco1
Buildi g Permit Info:
Bldg ❑ Elect Plumb Mech l'
Job D scripti :
CQ � O (
Resid tial Commercial ❑
Cost of Project: $ C—)
• Strapp d El On Platform 0 Bonded El
New cation ❑ Replacement ❑
Qty. if
A li able Fee ID Fee Description Fee Group
BPWHEATER Water Heater/Vent BUILDING
PPERMITFEE Plumbing Permit Issuance PLUMBING
BENERGY Energy BUILDING
BUSLIC Business License BUILDING
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