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12020057 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10148 PRADO VISTA AVE CONTRACTOR:PARVATHANENI PERMIT NO: 12020057 CHAKRAVARTHY AND LANKA OWNER'S NAME: PARVATHANENI CHAKRAVARTHY AND LANKA 10148 PRADO VISTA DR DATE ISSUED:02/13/2012 OWNER'S PHONE: 4083933645 CUPERTINO,CA 95014 PHONE NO: Q LICENSED CONTRACTOR'S DECLARATION .,.M __ BUILDING PERMIT INFO: BLDG ELECT PLUMB' License Class L.ic.# MECH RESIDENTIAL COMMERCIAL Contractor Date I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:INSTALL TEMP POWER POLE (commencing with Section 7000)of Division 3 of the Business&Professions Code and that my license is in full force and effect. I 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. Sq.Ft Floor Area: Valuation:$500 1 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 permit is issued. APN Number:34214093.00 Occupancy Type: APPLICANT CERTIFICATION 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 PERMIT EXPIRES IF WORK IS NOT STARTED to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We)agree to save WITHIN 180 DAYS OF PERMIT ISSUANCE OR indemnity and keep harmless the City of Cupertino against liabilities,judgments, 180 DAYS FROM LAST CALLED INSPECTION. costs,and expenses which may accrue against said City in consequence of the granting of this permit. Additionally,the applicant understands and will comply _ with all non-point source regulations per the Cupertino Municipal Code,Section Issued It, ��_' Date: Z 9.18. ' Signature Date RE-ROOFS: OWNER-Btf[L,DER DECLARATION All roofs shall be inspected prior to any roofing material being installed.If a roof is installed without first obtaining an inspection,I agree to remove all new materials for I hereby affirm that I am exempt from the Contractor's License Law for one of inspection. the following two reasons: 1,as owner of the property,or my employees with wages as their sole compensation, Signature of Applicant: Date: will do the work,and the structure is not intended or offered for sale(Sec.7044, Business&Professions Code) 1,as owner of the property,am exclusively contracting with licensed contractors to ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER construct the project(Sec.7044,Business&Professions Code). I hereby affirm under penalty of perjury one of the following three HAZARDOUS MATERIALS DISCLOSURE declarations: I have read the hazardous materials requirements under Chapter 6.95 of the I have and will maintain a Certificate of Consent to self-insure for Worker's California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain Compensation,as provided for by Section 3700 of the Labor Code,for the compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health& performance of the work for which this permit is issued. Safety Code,Section 25532(x)should[store or handle hazardous material. I have and will maintain Worker's Compensation Insurance,as provided for by Additionally,should I use equipment or devices which emit hazardous air Section 3700 of the Labor Code,for the performance of the work for Which this " contaminants as de d by the Bay Area Air Quality Management District I will permit is issued. maintain con ' nce. h ie Cupertino Municipal Code,Chapter 9.12 and the f . I certify that in the performance of the work tier which this permit is issued,I shall !"I ea S e Code, a ions 25505,25533,and 25534. not employ any person in any manner so as to become subject to the Worker's -Own a orize a t: Compensation laws of California. If,atter making this certificate of exemption,I Date: 3 )1, become subject to the Worker's Compensation provisions of the Labor Code,I must forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCl I hereby affirm that there is a construction lending agency for the performance of wr�rk's APPLICANT CERTIFICATION for which this permit is issued(Sec.3097,Civ C.) I certify that I have read this application and state that the above information is Lender's Name 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 eater Lender's Address upon the above mentioned property for inspection purposes.(We)agree to save indemnify and keep harmless the City of Cupertino against liabilities,judgments, ctiosts,and expenses which may a ue against said City in consequence of the ARCHITECT'S DECLARATION granting of tl t.A for lly,the applicant understands and will comply I understand my plains shall be used as public records. with all n -poi t urc reg l tions per the Cupertino Municipal Code,Section 9.18. �7 Licensed Professional Signature Date L.` (-3 1 2' CITY OF CUPERTINO 6 ITEMS OF 6 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN . . . . . . . . : 34214093 .00 DATE ISSUED. . . . . . . : 02/13,/2012 RECEIPT #. . . . . . . . . : BS000016002 REFERENCE ID # . . . : 12020057 SITE ADDRESS . . . . . : 10148 PRADO VISTA AVE SUBDIVISION . . . . . . CITY . . . . . . . . . . . . . . CUPERTINO IMPACT AREA . . . . . . . OWNER . . . . . . . . . . . . : PARVATHANENI CHAKRAVARTHY AND ADDRESS . . . . . . . . . . : 10148 PRADO VISTA DR CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM . . . . : CHAKRAVARTHY PARVAT CONTRACTOR . . . . . . . . LIC # *OWNER* COMPANY . . . . . . . . . . : PARVATHANENI CHAKRAVARTHY AND ADDRESS . . . . . . . . . . : 10148 PRADO VISTA DR CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 TELEPHONE . . . . . . . . FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- ---------- 1ADMIN HOURS 1 .00 41. 00 0 . 00 41 .00 0 .00 1BCBSC VALUATION 500 .00 1 . 00 0 . 00 1 .00 0.00 1BSEISMICR VALUATION 500 . 00 0 . 50 0 .00 0 .50 0. 00 1EPERMITFE FLAT RATE 1 .00 44 . 00 0 .00 44 .00 0 . 00 1ERT<200 UNITS 1 .00 44 . 00 0 .00 44 .00 0 . 00 1TF..AVDOC FLAT RATE 1 .00 44 .00 0 .00 44 .00 0 . 00 ---------- ---------- ---------- ---------- TOTAL PERMIT 174 .50 0 . 00 174 .50 0 .00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CHECK 174 .50 #546 --------------- TOTAL RECEIPT 174 .50 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 402 TEMPORARY POWER CITY OF CUPERTINO FEE ESTIMATOR- BUILDING DIVISION ADDRESS: 10148 prado vista dr. DATE: 02/13/2012 REVIEWED BY: bobs. APN: BP#: VALUATION: $500 PERMIT TYPE: Electrical Permit PLAN CHECK TYPE: Alteration /Addition/ Repair PRIMARY SFD or Duplex PENTAMATION 1 REAP14 USE: PERMIT TYPE: WORK install temp power pole. SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Temporary Power 1ERT<200 100 Amps $44 TOTALS: $44.00 Elec.Plan Check 0.0 Frs $0.00 Elec.Permit Fee: 1EPERMIT Other Elec.Insp. El hrs $44.00 NOTE: This estimate does not include fees due to other Departments(i.e.Planning,Public Works,Fire,Sanitary Sewer District,School District,etc.). These.Lees are based on the grelinjina information available and are only an estimate. Contact the De 11 or addn'l info. FEE ITEMS (Pi 1 t'.=� -t� : ' % /i FEE QTY/FEE MISC ITEMS PME Plan Check: $0.00 PME Unit Fee: $44.00 PME Permit Fee: $44.00 Administrative Fee: 1ADMIIV $41.00 Work Without Permit? 0 Ices (D No $0.00 Travel Documentation Fee: ITTM VDOC $44.00 -'`I-o m.! tvl o fl o t e,,-: _� 1BSEI,S'MICR $0.50 Select an Administrative Item l-plc?:-_*arcss Co m_issiora._Ft�e IBCBSC $1.00 SUBTOTALS: 1 $174.501 $0.00 TOTAL FEE: $174.50 Revised: 1/19/2012 I ; � D �..-,��: r-7 GENERAL PERMIT APPLICATION MEP COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 10300 TORRE AVENUE-CUPERTINO, CA 95014.3255 (408)777-3228•FAX(408)777-3333•building(8cupertino.org misc CUPERTINO ❑PLUMBING ❑MECHANI�CJAL ELECTRICAL ❑MISCa AN OUS PR07ECT ADDRESS / Q/ APN x -32 z` l - OWNERNAI r\ PHONE`1 E-MAII. cI� eve v J3 -34, W5 STREET ADDRES F �� CITY,STATE,ZIPS�� L L� c T FAX CA CONTACT NAME u , PRONE ! E-MAIL <` ��(-� 1�aruc Vt,, v 3�3 -3�Y5 STREECADDRESS- f � L l/� n `G tr' CITY,STATE, G. 1^ (/� U S 9 7U�� FAX ❑OWNER OWNER-BUILDER ❑ OWNERAGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPF3! ❑TENANT CONTRACTOR NAME?,.,e� ( e e v l� LICENSE NUMBER 7 2 LICENSE TYPE BUS.LIC M COMPANY `` rU E-MAII. FAX STREET ADDRESS CITY.STATE, PHONE Sc ( a 5 ARCHITECT/FNGINEER NAME LICENSE NUMBER BUS.LIC A COMPANY NAME' E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE USE OF ETSM ar DUPLEX ❑ MULTI-FAhMY PROJECT IN WIIMLAM ❑ YES PROJECT1N ❑YES IS THE BLDG AN ❑YES BUIIDING: ❑COMMERCIAL URBAN WrE1tFACE AREA 13 NO FLOOD LANE ❑NO EICHM HOME! ❑No DESCRIPTION OF WORK rD L-e1 C < r i�a, a-1,LcA uJ r-1 { TOTAL VALUATION:` ��j� RECEIVED BY: By my signature below,I certify to each of the fbllawing: I am the property owner or authorized agent to act on the property owner's behalf I have read this application and the information I have provided is correctj have read the Description of Work and verify it is accurate. I agree to courply wits;all applicable local ordinances and state laws relating to g construc'on`I authorizeregrqentatrves of Cupertino to enter the abave4deatified property for inspection putposes. Signature of Applicant/Agent: Date: SUPPLEMENTAL INFORMATION 1EQUMED OFFICE USE ONLY ra OVER-THE.COUMXR d ❑ EXPRESS Y U M ❑ STANDARD T U ❑ LARGE a ❑ MMOR MEPA&cApp 201 Ldoc revised 06/21111