03070028 (2) CITY OF CUPEWI'INO 11,77777777a ' a,
BUILDING DIVISION PERMIT INFORMATION
BOILDING ADDRESS: SHARMA SURENDRA P AND DURG P E'lo3070028
• OWNER'S NAME: PERMIT ISSUE DATE
]NE: SANITARY NO. CONTRO1_NO.
ARCt11TECflENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
300 LICENSED CONTRACTOR'S DECLARATION Job Description
m I hereby alarm that l am Branded under prevision,of Chapter 9(commencing p
with Section 7011)of Division 3 of the Business and Professions Code,and my license is ��aV�W�m��
t^ in full Come and effect.
uns
ceeClas, Lte.a ADD SINK TO THE DRAIN LINE
�Fp Dao Cummcrer
rt•q ARCIImRCTSDECLARATION JUL u 2003
2 1 understand my plans shall be used as re
public cords
e Licensed Professional
1 OW NEOER DECLARATION
BUILDING
i 1 hereby affirm that 1 orem exempt from the Contractors License Law for the
3 M 0 following remnn.(Section 7031.5,Business and Profession,Code:Any city m roomy
which requires a whit to construct,alter,improve,demolish,or repair any structure
_Z< prior as its issuance.also requires the applicant(Of such permit to File a signed sutcmcm
that he is licensed punoam to the provisions orthe Contractor's License Law(Chapter 9 Sq. Ft. Floor Area Valuation
F�15 (commencing with Section 7050)of Division 3 of the Business and Professions Code)or
i that he u exempt thcmfmm and the baso for the alleged exemption.Any violation of 36939006 . 00
Section 7031.5 by any applicamfor apcnou bjce.lhaapplicant toacivilpenaltyof APN Number Occupancy Type
not mom than five hundred dollar,($500).
1,as owner of the publicity.of my employees with wage,Is theif,ole compensation,
I do Ne wok and theswctum isnot crowded aorfemd for,alf(Sao.7044,Business I U _ SEWER ll�cgg pCC
and Prefesaiona Code:The Contractors thereon,s License Law does no,apply to an owner of 2 0 2 — UNDERFLOOR PLUMBING
properly who builds or improveereon,and who does such work himlfuorthmugh his
awn employees.provided final uch improwmenu arc not intended or offem4(mule.If. 301 — ROUGH PLUMBING
however,the building or improvement is Sold within one year of completion.Ne owner.
builder will have the burden of proving that he did not Wild or improve for purpose of 3 02 — TUB &. OR SHOWER
.it).
E]1.as owner of the progeny,am exclusively contracting with licensed contractors to 502 — FINAL PLUMBING ENERGY
conswct the pmjml(Sec.70s4,Business and Professions Code:)The Contractor's Li. 506 — GAS TEST
Cone,Law data not apply to an owner or property who Wilds or Improve.,Bunton,and, 507 — FINAL PLUMBING
who contracts(or such projects with a contractor(&)licensed pursuant o the Contractors
License Law.
Iama rup7unt�I
t fder Sec. y�f .B&P C for this maven
net �' I J :12:V`^t Date
WORK 'S COMPENSATION DECLARATION
I hereby alarm under penalty of perjury no of[be fnllowing declaSations:
1 have and will maintain a Cenifmam of Consent to aelf-insure for Worker'sCompere
as on,as provided for by Section 37M of the IsWr Code,for the performance of the
work for which this permit is issued.
❑1 have and will maintain Worker's Compensation Insurance,as required by Section
3700 of Ne Labor Code,for to performance of the work for which this permit is issued.
My Workers Compematinn Imumnee Cartier and Policy nu nw,am:
Cartier: Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thus Section need not bocompleod if the perms,is for one hundred defim(5180
or lcs,J
1 certify that In the performance of the work for which this permit is issued.I shell not
employ any person in any manner an ss to become Subject o the Workers'Compensation
Laws of California.Data
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject to the Worker's Can PC nation provisions of the Labor Cndc,you must
O forthwith comply with such pmvisi.n.Cor this permit,hall he deemed mucked,
z CONSTRUCTION LENDING AGENCY
'rte I hereby affirm drat there i,a convection lending agency for performance of
C' the work for which this permit is issued(SCC.367,Civ.C.)
fA A lender',Name
z Under's Address
U Q 1 certify Nu I Mw read this application and sum tau dm above information is
U. F correct.1 about to comply with all city and county ordinances and Slam laws mleing to
Q V building convection,and hereby amhoriee repwenCrOeauf this city to enter upon the
r abovamerthowd pmperly for Impaction purposes-
(1. (We)agree Io Save,indemnify and keep haneless the City of Cupertino against
b zy rue liabilities, costs and expenses which may in any way accagainst said City
in of the granting of
U^ APPLICACNTCUNDERSTANDSIAIND WILL COMPLY WITH ALL NON-POINT Issued by:s4taza Date
SOURC F. LATIONS.
1 Urt_ j 7 . 3 0 3 Re-roofs
Signature ofXpplicanalColluormot Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant store or handle hazardous material
as cleaned by the Cupertino Municipal Code.Chapter 9.11,and the Health and Safety
Code,Section 25531(a)? All roofs shall be inspected prior to any roofing material being installed.
Inner❑Yes KNu
Will the applicant or fmuic building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
?
t havardova air Sams curnins.ss defined by the Bay Area Air Quality Managcmont all new materials for inspection.
❑Yon INNo
I have mad the haramousmaorlals requirements under Chaphn6.95 of the Califon
nix Heeltb&SaRty Cak,Sec mor 25505.25533 am125534,1 wasermnd dot ifthc Wilding
data not currently haw a mnanL that it u my responihility to notify to mcupart of the
relfiremcnu which must be met pnormis uahcc ofa Ccrtificme of Occupancy. Signature of Applicant Date
. liAg% 9, 4 i O All roof coverings to be Class "B" or better
Owner or out urircd agCOO Dam
OWNER-BUILDER VERIFICATION
1. (Check one) I or my immediate family (parent, spouse or child) will perform:
A. X All the work authorized by this permit
B. _ A portion of the work
C. _ None of the work
If B or C is checked,complete 2 or 3 below.
2. A state licensed contractor will be hired to do:
A. _ All of the work
B. _ A portion of the work (complete section below)
Contractor Address/City Phone # State License # Type of work to
be performed
3. _ I will utilize unlicensed person(s) other than my immediate family to perform all or
portions of the authorized work. I understand that I may be an employer (see reverse side). A
Certificate of Insurance covering workers' compensation must be on file at the City of
Cupertino Building Department office.
Person/Firm Address/City Phone Number Type of work to be ,
performed
...................................................................................................................................................................................
I declare under penalty of perjury that the above is true and correct. I have read and understand the
Owner-Builder Information (reverse side). I ,
Property Owner's Signature: �• JD �A2�:✓ Date: m 7 ' 3 03
Job Address: 2_0 3 O 9 / Cn cI �� • Permit# O 3 O 7 U O 2
Any changes to the information provided on this form shall be submitted to the City of Cupertino Build
Department.
r antsCITY OF CUPERTINO C3'
3� 7 0 o Z�
CUPERTO PERMIT APPLICATION FORM
N# 3 / 3 v o Date: �7 3 0 3
Building Address: ; ,03C59 S l v mcJ o Axle
Owner's Name: .5U (Le N -DRA S H A 12 " A / Phone #: H O 8- , cl q G o20 36
A Lt (2-aA PAL-
Contractor:
ALContractor: 0wy\A^ License #:
Contact: Cupertino Business License#:
Building Permit Info(J)A,,�C( i R�[,�� o -f cL --: w ;wt
.'
Bldg ❑ Elect [r Plumb ® Mech ❑
Job Description:
Residential IZ Commercial ❑
Sq.Ft. Floor Area: $/Sq.Ft.:
Cost of Project: I SO f Occupancy Group:
Type of Construction: l
AL
Quantity Fee ID Fee Description Fee Group
BAPPLOTHER Other Appliances MECHANICAL
BBLDGFEE Bldg Permits . foot BUILDING
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
BELEC 1001 Elec 600V> 1000A ELECTRICAL
BELEC200 Elec Svcs 600V <=200A ELECTRICAL
BENERGY Energy BUILDING
BENERGYADD Energy Add Multi BUILDING
Aik BINVESTIGA Investigation fee BUILDING
BMITIGATC Comm. Housing Mit. Fee BUILDING
223 7 �
" lof3
�3
CITY OF CUPERTINO
CUPEkTINO PERMIT APPLICATION FORM
I�T
Quantity Fee ID Fee Description Fee Group
BMITIGATR Res. Housing Mit Fee BUILDING
BMNEWMULTI New Multi-Family Res MECHANICAL
BMNEWSF&2F New Sf&2F Res Bldgs MECHANICAL
BNEWMULTI Multifamil Res ELECTRICAL
BNUCOMME New Comm Electric ELECTRICAL
BNUCOMMM New Comm Mechanical MECHANICAL
BNUCOMMP New Comm Plumb PLUMBING
BNUMULTI New Multifamily Res PLUMBING
BNUSFD New Single Family Res BUILDING
BOVERTIME 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 HeaterNent PLUMBING
BPWSVCS Main Water Service PLUMBING
BREINSPECT Reinspection Fee BUILDING
BREMACOVER A/C Unit> 10,000 cfm MECHANICAL
BREMAMIAN A/C Units <= 10,000 cfm MECHANICAL
BREMAPPLI Appliance Install MECHANICAL
BREMBUSWAY Remodel Busways ELECTRICAL
BREMFDXT Lighting Fixtures ELECTRICAL
BREMFURN Relocation of Fumace 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
2 of 3
CITY OF PER
U TINO
CUP TYOF O PERMIT APPLICATION FORM
QuantityFee ID Fee Descri tide Fee Group
BREMPOWER Power Device/Apparatus ELECTRICAL
BREMRECEPT Rc tl, Switch & Outlets ELECTRICAL
BREMRELOCA Relocation of Hood MECHANICAL
BREMREPALT Repair/Alter Heating MECHANICAL
BRENMSAPP Remodel Res Appliance ELECTRICAL
BREMSIGNAD Rmdl Signs Add Branch ELECTRICAL
BREMSIGNS Remodel Sips,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 Inspection 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 Issuance PLUMBING
PPLBG Plumbing Fee sq foot PLUMBING
ZADDCHG Address Chane BUILDING
•
3 of 3