12030139 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 20995 PEPPER TREE LN CONTRACTOR:JON R CRASE PERmn ,No: 12030139
CONSTRUCTION INC
OWNER'S NAME: ANURADHA PARTHASARATHY 164 GILMAN AVE STE A DA IT ISSUED:03/28/2012
OWNER'S PHONE: 4082186847 CAMPBELL, CA 95008 PHONE NO:(408)370-1485
LICENSED CONTRACTOR'S DECLARATION r r r
BUILDING PE;RMI'I'INFO: BLDGE;LF,CI' vLCMB
License Class l.ic.6 r r r
xl EC11 RESIDENHAL COMMERCIAL
Contractor Dale
1 hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION- REPAIR 64 SQ PI"I'O DAMA(ii:I'RAA11:.STUCCO ANO
GYPSUM
(commencing with Section 7000)of Division 3 of the Business&Professions BOARD DUE IO AUTOMOBIIT AC'CIDEN'I"
Code and that my license is in full force and effect.
1 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,us provided for by Section 3700 of the Labor Code,for the
performance of the work for which this permit is issued. Sq.Ft Fluor Area: Valuation:S6000
I have and will maintain Worker's Compensation Insurance,as provided for by
Section 3700 orthe Labor Code,for the performance of the work for which this
-w— APN Number:35912019 00 Occupancy'rrpe:
permit is issued,
APPLICANT CERTIFICATION
I certify that 1 have read this application and stale that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED
correct. I agree to comply with all city and county ordinances and slate laws relating WITHIN 180 DAYS OF PERMIT ISSUANCE OR
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned properly for inspection purposes (We)agree to save 180 DAYS FR=SCALLED INSPECTION.
indemnify and keep harmless the City of Cupertino against liabilities.judgments.
costs,and expenses which may accrue against said City in consequence of the 3 2�_I Z
granting of this pcnnit. Additionally,the applicant underst:mds and will comply Issued by: Dale:
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18.
HE:ROOF'S:
Sign:tur Irl, t.4 '�'I. Date All roofs shall be inspected prior to any roofing material being installed II'a roof is
installed without first oblainin_an inspection.I agree to remove all new materials for
inspection.
❑ OWNER-BUILDER DECLARATION
Signature of Applicam Date:
1 hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BE:ITER
1,as owner of the property.or my employees with wages as their sole compensation,
will do the work,and the structure is not intended or offered for sale(Sec.7044,
Business&Professions Code)
I,as owner of the property,am exclusively contracting with licensed contractors to I IAZARDOUS,MATERIALS DISCLOSURE:
construct the project(Sec.7044,Business&Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the
California Health&Safery Code,Sections 25505,25533,and 25534. 1 will
hereby affirm under penally of perjury one of the following three maintain compliance with the Cupertino Municipal(:ode.Chapter 9.12 and the
declarations: Ilealth&Safety Code,Section 25532(a)should I store or handle hazardous
I have and will maintain a Certificate of Consent to sell'-insure for Worker's material. Additionally,should I use equipment or devices which emit hazardous
Compensation,as provided for by Section 3700 of the Labor Code,for the air contaminants as defined by the Bay Area Air Quality Management District
performance of the work for which this permit is issuedwill maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sections 5505.2553 rd 25534.
Section 3700 o(ihe Labor Code,for the performonee of the work fiir which this yj� 3
permit is issued Owner Or authorized agent: ��(rl.'Li.l'$� '✓1 Dale:
I certify that in the performance Of the work for which this pcnnit is issued I shall
nal employ any person in any manner so as to become subject to the Worker's
Compensation laws of Cal ifomia- If,after making this certificate of exemption..I CONSTRUC-ZION LENDING AGENCY
become subject to the Worker's Compensation provisions of the Labor Code,I must I hereby affirm that there is a construction lending agency for the performance of
forthwith comply with such provisions or this permit shall be deemed revoked. w'ork's for which this permit is issued(Sec.3097,Civ C.)
Lender's Name
APPLICANTCF,RTIFICATION Lcnder's Address
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
to building construction,mid hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes.We)agree to save
indemnify and keep harmless the City ol'Cupertino against liabilities,judgments, ARCIITfE.0"T'S DECLARA"IION
costs,and expenses which may accrue against said City in consequence of the I understand my plans shall be used;w public records.
granting of this permit.Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section I.icensed Professional
9,18.
Signature Date
t
RESIDENTIAL PROJECT COVER SHEET
Assessor's Parcel Number:
Name of owner. 10.x4y�50.(� S.� wc�owa C
Project address. FQAOII!K402-- 1A,;8 ' t.bna-I n-o Q q `P5e,1Y
Contact person. Phone. 0,00 (o�Ft)- S9 (o5
Fax. ( 1910 37D-na319
Net square footage of lot.
Existing Proposed
Square footage: First floor:
Second floor:
Garage:
TOTAL:
Are there at least two 10 foot by 20 foot clear spaces inside the garage? Y N
Is privacy protection planting required for the project? Y 61� I2I�CR1 VPD
Build it Green Total Points MAR 28 2U12
On what floor(s) is work being done? ST BY:
Brirefdescriptionofwork. V- rod ry4,,�4.c.A rtA. -e- W4lU SEVA5 VA&JH t0,n0(nt,7,
cL-L1 f"O:i r IZ-13y�auf. r-1-;x�✓
Code editions: 2010 CBC (Y- N)2010 CFC (Y- N)2010 CMC (Y-N)
2010 CPC (Y- N)2010 NEC (Y-N)
California Green Building Standards Code 2010
COMMUNITY DEVELOPMENT DEPARTMENT
BUILDING DIVISION-CUPERTINO
Effective 1/O1/11 APPROVED
This set of plans and specifications MUST be kept at the
job site during construction. It is unlawful to make any
changes or alterations on same,or to deviate
///ryyy therefrom, without approval from the Building Official.
F
�� ®�� The stamping of this plan and specifications SHALL NOT
be held to permit or to be an approval of the violation
C E C
of any provisions of any City Ordin ce or Stale Law.
i; BY
DATE 3'
PERMIT NO. 20 3 of 3 9
Plan Review Process Work Book Page -8- Revised 12/21/10
COMMUNITY DEVELOPMENT DEPARTMENT
BUILDING DIVISION-CUPERTINO
APPROVED
np
This set of plans and specifications MUST be kept at the
y ___ job site during construction It ig IinIFkwf.d to ml.
cnn.,ny
�ianges or alterations on same,or to deviate
therefrom,without approval from the Building Official.
The stamping of this plan and specifications SHALL NOT
be held to permit or to be an approval of the violation
of any provisions of any City Ordinance or State Law.
BY
DATE
PERMIT NO.� �9
1
r<..wo or. a�ol rtplw�
axy 64-LA--3 V� w 1-%, (,o > RECE1VED
MAR 28 2012
sBY:
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eproK �4 sF
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ACID CERTIFICATE OF LIABILITY INSURANCE OA 812'011
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER, THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY
AMEND.EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),
AUTHORIZED REPRESENTATNE OR PRODUCE AND THE CERTIFICATE HOLDER.
IMPORTANT: 11 the cermhFate WNL",¢M ADDITIONAL INSURED.0a8gIcy(w)must be endorsed- II SUBROGATION IS WNVED.suDIKI to the Mrns and=250116 of the pdiq.oeean pdpiea may require an
endorsement.A slatemeol on this Cbrftate does not a hls 10 IheoedfCate MICW in leu of such eMuaemeoi s.
Pmducc 408-271-2300 CONTACT NAME:
Y.A. Tittle& Associates Insurance Services 408-271-1802 PHONE 866-966-8928 FAX 408-271-1802
P.O. Box 1960 WC,No,Fx):
San Jose,CA 95109-1960
E-MAIL
ADDRESS:
INSURER(S)AFFORDING COVERAGE ;NAIC#
INSURED INSURER —Ecere—sl Nario_n.n..l..In._s—uran-c_e.C_on_pili v
Jon R. Crase Construction,Inc. INSURER& - "-"-
164 Gilman Avneue I INSURERC: "---'-""""---
Campbell,CA 95008 INSURER D
INSURER E -------
INSURER R. - --
_ COVERAGESCERTIFICATE NUMBER. REVISION NUMBER _
THIS IS TO CERTIFY THAT_THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAME ABOVE FOR THE POLICY PERIOD INDICTED. NOTWITHSTANDING ANY
REOUIREMENT,TERM OR CONDITION OFANY CONTRACT OR OTHER DOCUMENT WITH RESPECTTO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE
POLICES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS.EXCLUSIONS AND CONDITIONS OFSUCH POLICIES. WITS SHOWN MAY HAVE BEEN REDUCED BY PAIDCWMS.
I INSR TYPE OF INSURANCE ADO SUBR POLICY NUMBER POUCY EFF POLICY EXPWLIMITSON,ITSINSR WVp MWD0 MMIDDGENERAL LIABILITY RRENCE 5❑COMMERCIAL GENERAL LIABILITY RENTED 5❑❑CLAIMS-MADE ❑OCCUR Ea=,ena)❑ ny on peRor) S ADV INJURY 5GGREGATE 5GEN'L AGGREGATE LIMIT APPLIES PER COMP/OP AGG S
❑POLICY ❑ PROJECT ❑ LOC j $
AUTOMOBILE LIABILITY I� EI T-1.IE COMBINED SINGLE LIME 5
❑ANY AUTO �.r I.'iA Yom' (Eaatident)
❑ALL OWNED AUTOS MAR 2@ cui2 BODILY INJURY(Per Person) S
[I SCHEDULED AUTOS
BODILY INJURY(Per Aspiden0 5
❑HIRED AUTOS BIj. PROPERTY DAMAGE
[I NON-OWNED AUTOS (Por amident) S
❑UMBRELLA UAB ❑ OCCUR EADIOCCURRENCE S
❑EXCESS UAB ❑ CLAIMS-MADE I AGGREGATE S
❑DEDUCTIBLE
❑RETENTION 8
ER PENSATION29 WC BTA LL M
AND EMPLOYERS'LIABIUTv 7600004189121 01/01/12 01/01/13 TORY LIMITS ER
ANIYPROPRIIETORNARI IAFiECUTNE YN El EACH ACCIDENT
A OFFEERNEAeERIEXCLUDED ❑ WA 5 1.000.000
Naas ,WKH)
Ilya.descnbe under DESCRIPTION OF I EL DISEASE-EA EMPLOYEE S 1.000,000
OPERATION bepw EL DISEASE-PQUCY UMI 5 1,000.000
DESCRIPTION OF OPERATIONSLOCATIONSNEHICLES WLwh ACOID 101,AcWtiond Remoras SCledde.N we space is le9lmed)
RE:
ISSUED FOR%%'ORKERS'C.031PENSAI-ION RENEN'.4L ONLI'
NOTE:30 DAYS NOTICE OF CANCELLATION WILL BE GIVEN EXCEPT 10 DAYS FOR NON-PAYMENT.
CERTIFICATE HOLDER CANCELLATION
j SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH
City of San Jose THE POLICY PROVISIONS j
Risk Management
j 200 E.Santa Clara Street,Hing 2nd Floor AUTHORIZED REPRESENTATIVE
San Jose,CA 95113
__ed,_._..._ — — -- -
ACORU 75IT009109) The ACORO namearW p90 are registered marks of ACORD 019887005 ACORJ CORPGRAiiOi All rignls reserved
CITY OF CUPERTINO
FEE ESTIMATOR- BUILDING DIVISION 120 3D 3
ADDRESS: 20995 Peppertree In DATE: 03/28/2012 REVIEWED BY: Sean
APN: BP#: i -VALUATION: $6,000
*PERMIT TYPE: Building Permit I I PLAN CHECK TYPE: Alteration / Repair
PRIMARY SFD or Duplex PENTAMATION 1GENRES
USE: PERMIT TYPE:
WORK a air 64 sq/ft dama e•to.frame stucco and gypsum board by auto crash.
SCOPE
i
Mech. Plan Check Plumb. P[(..Cheek
lilee. Plum Ch'ek
Neck Perruil Fee: I Plumb. Permit Fa•: Eley Permit Fre:
I
Ulcer.1 fech. ln.sp. Other Plumb lasp. Li 011ier E/cc. /s.tip. El
:I/,!(11. /nop. Fre: Plumb. bull?. rue: Elec.Imp_Fee:
NOTE: This estimate does not include fees due to other Departments(Le. Planning,Public Works, Fire,Sanitary Sewer District,School
District,etc). Thesefees are based on the preliminary information available and are only an estimate Contact the De t or addn'l info.
FEE ITEMS (/--cc Resohnion 11-053 EIL 7/1/11) FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 64 s.f.. Siding
Suppl. PC Fee: Q Reg. 0 OT 0.0 1 hrs $0.00 $392.00 ISIDEOTHER I All Other
PME Plan Check: $0.00
Permit Fee: $0.00
Suppl. Insp. Fee-.0 Reg. Q OT 0,0 1 hrs $0.00
PME Unit Fee:
$0.00
PME Permit Fee: $0.00
Consli action Tax:
Administrative Fec: O
Work Without Permit? O Yes (E) No $0.00 E)
Advanced Planning Fee: $0.00 O
i
Tru rel Documcnlarinn Fees:
Q'
Strong Motion Fee: IBSEISMICR $0.60 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC I $1.00
SUBTOTALS: $1.60 $392.00 TOTAL FEE: 1 $393.60
Revised: 19
CONSTRUCTION PERMIT APPLICATION I�b36 3�
COMMUNffY DEVELOPMENT DEPARTMENT• BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO, CA 950143255
(408)777-3228• FAX(408)777-3333•buildina(a)cuoeftino ora � h �/S 4 /�
CUPERTINO ��/ �Gdhti f((y� �t
❑NEW CONSTRUCTION ❑ ADDmoN LTJ ALTERATION/TI ❑ REVISION/DEFEF= ORIGINAL PERM N
PROJECT ADDRESS ,7,D s Q Vt APN a
OWNER NAra S G`. PBONe aV1219-L407' E `.IL
v�t7r. t
SIREETADDRFSS Q S I EQ 1 , C[TY. STATE ZIP �L FAx
iv
CONTACT NAME n` PBONE I �&`q 7 E MA"
STREET ADDRESS —11^
?vv-"—:6e
.( /Cn CITY.STATE ztP Off! /..
QI OWNF]t ❑ OWNER--SURDER ❑ OWNER AGENT C❑ CONTRACTOR ❑CONTRACTOR AM' r ❑ ARCHITECT ❑PNGD®t ❑ DEVELOPER ❑TENAM'
CONTRACTOR NAMEw ^ IjCRNSE NUEIDER / LICENSE BUS.TIC p
n/I 7
COMPANY NAME T �/'1 _ BMAD' �C Q ♦ FA% D'cO�3g
STREET ADD%q lam" CITY.STAATTE
MCHTLECT/ENODJIDt NAME LICENSE NUMBER M.LIC.
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY.STATE ZIP PHONE
13ESCROMON OF WORK
M 1 &,tA ` Gl.j r
FJm CD+G USE
C'�� PROPS�Dv6"E ate/ USE TYPE OCC SQFT. VALUATION(S)
EXISTO✓ NEW FfOOR DEMO TOTAL
AREA AREA �_ AREA NETAREA �—
BATHROOM IDI4¢N OaIDt
REMODELARFA REMODELARFA REMODELAREA
roaCHAAPA DEOCAREA TOTAL DEUK RCH MEA GARAGEA - DETACH
ATTACH
O DWQIJNG UNITS: IS A SECOND INR" YES SECOND STORY YES
BIDNG ADDED? ONO ADDMOW.. ONO
FRE-APPLICArmN OYES IFYIMPROVIDECOFYOF IS TEE BLDG AN ❑YES RECIIVm HY: }'C7TAL VALUATION:
PLANNNGAPFL9 ONO PLWNINQAPPROVAL LETTER. EtcEmBOD�t ONO {!Yr OoO,''D
By my sigoaDax below,r certify to each cf the fbUcwmg: I am the Property owner or a aborized anent to act on the prpperty.owaces behalf,I have rad this
application and the infomantion I have provided is correcr.I have rad the Description of Work and verify it is acLgate. I agree to comply with an applicable local
ordinances and state laws muting to buildi ori=represcatarives Of Cope='0 to enter the abbcv -ideatied property for inspection purposes.
Signature of ApplicandAgat �Zq'�l—Y�"e T. Date: J p1-$ / .
SUPPLEVIEN'CALINFORMATIONREQUIItED
ELAN CBXCK TYPE ROUTatcsuP
New SFD or Multifamily dwellings: Apply for demolition permit for 11 ovRR Ttn<cOUNTEtT ❑ BLiD�ivc ELAN RKvrEw
existing building(s). Demolition permit is requited prior to issuance of building
permit for newbuiildng. ❑ EXPRESS ❑ PLANPNGPLAN REVMW
Commmr
—Commercial Bldgs: Provide a completed Hadous Materials Disclosure ❑ STANDARD ❑ PUBLIC WORM
form if any Hazardous Materials are being used as part of this project ❑ LARGE ❑ FrEz ozrr
Copy of Planning Approval Letter or Meeting with Planning prior to ❑ M.UOR ❑ SAMTMY SEWIM DISTRICT
submittal of Building Permit application
❑ ENVERONMffiYIAL HEALTH.
B1dgApp 2011.doe revised 06121/71