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12040106 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 7578 NORMANDY WAY CONTRACTOR:A&I I I1EATING PERMIT NO: 12040106 OWNER'S NAME: PRAVEEN AMANCHBRLA&PADMAJA MANTRA 770 CIIESTNUI'ST DATE; ISSUED:04/182012 OWNER'S PI IONS: 4086668063 SAN JOSE.C\ 95110 PIION):NO:(408)279-0722 ❑ LICENSED CONTRACTOR'S DECLARATION r r r ,,pp BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class (:—ZQ Lic.q �CP y Cf z !,. (}y �— /�—/�� MECH r RESIDENTIAL r COMMERCIAL r COnlraclor /Y'7�{-I'/ (T Uatc 1 hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION: RfiLDCAI'G C:XIS"PING FURNACE 10 11 11:1 (commencing with Section 7000)of Division 3 of the Business&Professions GARAGI:,Lxri7ND GAS Code and that my license is in full force and effect. &11.1:C I RICAL,NEW FIME,EX fl"ND DUCTING 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. 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 Sq.Ft Floor Area: Valuation:S3700 permit is issued. APPLICANT CERTIFICATION APN Number:36617062.00 Occupancy Type: 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,and hereby authorize representatives of(his city to enter upon the above mentioned property for inspection purposes. (We)agree to save PERMIT EXPIRES IF WORK IS NOT STARTED indemnify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City in consequence of the WITHIN 180 DAYS OF PERMIT ISSUANCE OR granting of this permit. Additionally.the applicant understands and will comply 180 DAYS FROM LAST CALLED INSPECTION. with all non-point source regulations per the Cupertino Municipal Code,Section 9-18- Signature ��'"�^�'��Vti-�"t/r�e l —/i5 -'Y2_ Issued by: ��f}I\/ /`1,6'e Date: y�B•l� ❑ OWNER-BUILDER DECLARATION RE:ROOF'S: I hereby affirm that 1 am exempt from the Contractor's License Law for one of All roof shall be inspected prior to any roofiue material being installed Ila roof is the following two reasons: installed without first obtaining an inspection.I agree to remove all new materials I'or I,as owner of the property,or my employees with wages as their sole compensation, inspection, will do the work,and the structure is not intended or offered for sale(Sec 7044. Business&Professions Code) Signature of Applicant Date: 1,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044,Business&Professions Code). \h1,ROOF COVERINGS 3'O BE CLASS",\"OR Bk"I-fE:R 1 hereby affirm under penally of perjury one of the following three declarations: 1 have and will maintain a Certificate of Consent to self-insure for Worker's IIAZARDOUS MATERIALS DISCLOSURE Compensation,as provided for by Section 3700 of the labor Code,for the I have read the hazardous materials requirements under Chapter 6.95 of the performance of the work for which this permit is issued. California I le:dlh&Safety Code,Sections 25505,25533,and 25534. 1 will maintain I have and will maintain Worker's Compensation Insurance,as provided for by compliance with the Cupertino Municipal Code,Chapter 9.12 and the Ileallh& Section 3700 of the Labor Code,for the performance of the work for which this Safety Code,Section 25532(a)should I store or handle hazardous material. Additionally,should I use equipment or devices which emit hazardous air permit is issued, contaminants as defined by the Buy Area Air Quality Management District 1 will I certify that in the perlbnnance of the work for which this permit is issued,I shall maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the mol employ any person in any manner so as to become subject to the Worker's l leallh&Safely Code,Sections 25505,25533,and 25534. Compensation laws of California. If,after making this certificate of exemption.I become subject to the Worker's Compensation provisions of the Labor Code,I must ter or authorized t forthwith comply with such provisions or this permit shall be deemed revoked. ate: O APPI.ICA\1'CER'I'IFICA'I'ION CONS"IRUCTION LENDING AGENCY 1 certify that I have read this application and state that the above information is I hereby affirm that there is a construction lending agency for the performance of work's correct. I agree to comply with all city and county ordinances and state laws relating for which this permit is issued(Sec.3097.Civ C.) to building construction,and hereby authorize representatives of this city to enter Lender's Name upon the above mentioned property for inspection purposes.(We)agree to save indemnify and keep harmless the City of Cupertino against liabilities,judgments, Lender's Address costs,and expenses which may accrue against said City in consequence ordte granting of this permit.Additionally,the applicant understands and will comply ARCHITECT'S DECLARATION all non-point source regulations per the Cupertino Municipal Code.Section 9.18- 1 understand my plans shall be used as public records. Signature Date Licensed Professional CITY OF CUPERTINO 6 ITEMS OF 6 PERMIT RECEIPT OPERATOR: suew COPY # 1 Sec : Twp: Rng: Sub: Blk: Lot: APN 36617062 . 00 DATE ISSUED. . . . . . . : 04/18/2012 RECEIPT 4 . . . . . . . . . : BS000016575 REFERENCE ID # . . . : 12040106 SITE ADDRESS . . . . . : 7578 NORMANDY WAY SUBDIVISION . . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . . OWNER PRAVEEN AMANCHERLA & PADMAJA M ADDRESS . . . . . . . . . . : 7578 NORMANDY WAY CITY/STATE/ZIP . . . : CUPERTINO, CA 95014-5223 RECEIVED FROM . . . . : DALE PHELPS CONTRACTOR . . . . . . . : PHELPS, DALE LIC # 12079 COMPANY . . . . . . . . . . : A & H HEATING ADDRESS . . . . . . . . . . : 770 CHESTNUT ST CITY/STATE/ZIP . . . : SAN JOSE, CA 95110 TELEPHONE . . . . . . . . : (408) 279-0722 FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---- ------ ----- ----- ---------- ---------- ---------- -ADMIN HOURS 1 . 00 41 . 00 0 . 00 41 . 00 0 . 00 1BCBSC VALUATION 3, 700 . 00 1 . 00 0 . 00 1 . 00 0 . 00 1BSEISMICR VALUATION 3, 700 . 00 0 . 50 0 . 00 0 . 50 0 . 00 1MFR=<100 UNITS 1 .00 130 . 00 0 . 00 130 . 00 0 . 00 1MPERMITFE FLAT RATE 1 . 00 44 . 00 0 . 00 44 . 00 0 . 00 1TRAVDOC FLAT RATE 1 . 00 44 . 00 0 . 00 44 . 00 0 . 00 TOTAL PERMIT 260 . 50 0 . 00 260 . 50 0 . 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ---------- ------- --------------- ----- --------------- CREDIT CARD 260 . 50 VISA --- ------------ TOTAL RECEIPT 260 . 50 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -- ----- ---------------------------- -- ------ - -- ---------------- 505 FINAL ELECTRICAL 507 FINAL PLUMBING 508 FINAL MECHANICAL GENERAL PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION (408) TORRE AVENUE•CU 7-3333 O,CA ng(cDcuv 55 I A CUPERTINO (�8)777-3228�FAX(408)777-3333• building(�cuoerCnO.orO /a (v' PLUMBING LVA CIIANICAL 1.n ELECTRICAL ❑MiSO L eNF0U5 FROIECT ADDRE45 q ��/ ©rZ* APN I OWNERNAME Y / 77 —�'�/( — PxOrre� zT—• STREET ADDRESS 571 FAX CONTACT NAME PNONE9902 rel 0 STREE[ADDA1�_7211 412� ISE ClTY `!/`f—CJ r�V P OD 27 7'�D� ❑ OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT W WMRAC[DR ❑CAMRACTOR AGINF ❑ ARCHOFIT ❑Ql@lIDt ❑ DEVQAPFR ❑TeW4T _ CO �'L� � �� LIC�NS.EER LICENSE Cif 6 BUS.LICP NTRAN 7 ASG- E — — L, (j"/t q0 ga.79la 7 n=ADD 77oCtF s��urg— a" "'� <2,* ss�v 0 2pro ARCIDTEC UENGMEFR NAME _ UCENSE NUMBER BUS.LIC P COMPANY NAME E-MAD. FAX STREECADDRFSS CITY.STAT1;ffi PHONE USE OF SFD m DUPLE% ❑ MULTI-FAMILY PROLFLTIN WIDLAND ❑ YEs PROIF=IN ❑YES ISTHERIDGAN ❑YES BUDDING ❑COMMERCIAL URRAN ENTWACEAREA 13 NO FLOOD 2X7NE E3 NO SCBISR HoME [3 NO OFSCAtPIlON OF WORK n z ' ^ � C /• '(- � F x rWyC� C7`fC t /((lzry l 1.Ce — FX 7-7E�/O uc-rj rD!'_ TOTAL VALUATION: 700 — U EMM BY: By my signature below,I certify to each of the following: I am the property owna ar authorized agent to act w the property awm's behalf I have rad this application and the hemmatiun I have provided is cortmeLd have rad the Description of Work and verify it is acem-am. I agree to comply with all applicable local ordinances and a=laws rela®g to btVCORS[rnedan. I as rttze�r!�r,aa�tWvva�offCCopertino m cuter the abov�e�-irdemi5ed property for inspection purposes. Sigaaarre of AppliaattAgcue �`'_y"Lw!/V//�--- Dam: —/ — 177 Z SUPPLEMENTAL INFORMATION REQUIRED. OFFICE USE ONLY yOVER-TBE-COUNTER d ❑ mum u d ❑ STANDARD 'u ❑ LARCH ❑ MAJOR MEPMacApp 2011.doc revised 06121111