12050038 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 20712 GARDEN PLACE CT CONTRACTOR:DEMPSTER PLUMBING PERMIT NO: 12050038
OWNER'S NANIE: KURAM NARAYANA&MALINI TADIMARRI 1639 POMONA AVE DATE ISSUED:05/032012
OWNER'S PHONE: SAN JOSE,CA 95110 PHONE NO:(408)295-3911
Cr LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL 11 CONiNIERCIAL
License Class C-_3Z Lic.q / S� �� REPLACE WATER SERVICE FROM METER TO HOUSE W/
-7'u 11... 4 � ...7 TYPE
Contractor
PS ,Date "L" COPPER PIPING -
I hereby affirm that 1 am licensed under the provisions of Chapter 9
(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:$200
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 APN Number:36230061.00 Occupancy Type:
permit is issued. /n
APPLICANT CERTIFICATION (�/
I certify that I have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED
correct.I agree to complywith all city and county ordinances and state 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 property for inspection purposes. (We)agree to save 180 DA F OM LAST CALLED INSPET ON.
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accmc a ainst said City in consequence of the
granting of this permit. may ,the icant understands and will comply Issued by: '� Date:
with all non-point source regular s per the pertino Municipal Code,Section
9.18.
RE ROOFS:
Signature Dale All roofs shall be inspected prior to any roofing material berg installed.If a roof is
installed without first obtaining an inspection,I agree to remove all new materials for
inspection.
❑ OWNER-BUILDER DECLARATION
:
1 hereby affirm that 1 am exempt from the Contractor's License Law for one of Signature of ApplicantDate:
the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
1,as owner of the properly,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 HAZARDOUS MATERIALS DISCLOSURE:
construct the project(Sec.7044,Business&Professions Code). 1 have read the hazardous materials requirements under Chapter 6.95 of the
California Health&Safety Code,Sections 25505,25533,and 25534. 1 will
1 hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
declarations: Health&Safety Code,Section 25532(a)should I store or handle hazardous
I have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally,should 1 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 lity Management District
performance of the work for whichthis permit is issued. will maintain compliance with the Cupertino Yunicil Code,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sections 25505.2 - 3 nd 5534.
Section 3700 of the Labor Code,for dieerfornance of the work for which this 3
permit is issued. p Owner or authorized agent: Dale:`S
I certify that in the performance of the work for which this permit is issued,I shall
not employ any person many manner so as to become subject to the Worker's
Compensation laws of Cali forma. If,after making this certificate of exemption,I CONSTRUCTION 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, work's for which this permit is issued(Sec.3097,Civ C.)
Lender's Name
APPLICANT CERTIFICATION Lender'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,and 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 of Cupertino against liabilities,judgments, ARCHITECT'S DECLARATION
costs,and expenses which may acerae against said City in consequence of the 1 understand my plans shall be used as 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 Licensed Professional
9.1&
Signature Dale
CITY OF CUPERTINO
FEE ESTIMATOR--BUILDING DIVISION
ADDRESS: 20712 Garden Place DATE: 05/03/2012 REVIEWED BY: Sean
APN: BP#: 'VALUATION: $2,000
*PERMIT TYPE: Minor Building Permit PLAN CHECK TYPE: Water Service
PRIMARY ResidentialPENTAMATION 1CPWS
USE: PERMIT TYPE:
WORK Re lace the water service from the meter to the house with type "L" copper piping.
SCOPE
APPLIANCE/EQUIP TYPE FEE ID BP FEES
Water Service Unit Fee: 1BPWSVCS $22
}/rah Plan Check Plumb. Plan Check F./ec.. Plan Check
drech, Penni/Feer: Plumb.Permit Fee: /PPERMIT I Elec. P.•rmii Fee:
Ocher,lfcrh. Insp. FJ I Oehrr Plumh Insp. $44.00 OeherElco.hasp. Li
Mrrh. hr.,p. Fee: Phuuh. hesp. Fee: filer. Pnsp. Fec:
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 prefindna in ormalion available and are only an estimate Contact the Diliffor addn7 info.
FEE ITEMS (Fce Resohition 11-053 Eff 711111) FEE QTY/FEE MISC ITEMS
Plan Check Few:
Sit/)/)/. PC Fee
Phanh.Al lech.lklec
l'e ntil Fec,.
Stipp/. hcsp Fea
PME Unit Fee: $22.00
PME Permit Fee: $44.00
Consavclicuc To.r:
Achninisirative Fcc:
Work Without Permit? O Yes Q No $0.00
Ach•aaceell'lannin,L Fees.
Travel Documenlmion Fees: A
Strong ,//noun f ce: Select an Administrative Item
131de, Stds Commission Fee: 1BCBSC $1.00
SUBTOTALS: $67.00 $0.00 TOTAL FEE: $67.00
Revised: 04/01/2012
GENERAL PERMIT APPLICATION M E P
COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DNISION
10300 TORRE'AVENUE,•CUPERTINO, CA 950143255 M I
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CUPERTINO (408)777-3228• FAX(408)777-3333• building(a�cuoertino.ora S o( .3
rp—LUMBING MECIIANICAL ❑ELECIR1cAL ❑MISCU.LANEDjp t�
PROJECT ADDRESS Z�--1 r z :� t/A i- PLxe-C � APN
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OWNER NAME U [[9' �✓! /I� FxoNa�06-ti.> -`"nD.
STREer ADDRESS� CrrY,STATE.LrP FAX
CONTACT NAME �i11 (� FHOVOSSq//� !Cgj�/ E-11AM .�la
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ADDRvea (� D"O J++e N "G srAr J� _� `A `7- F /Of�^e43q//
❑ ow ❑ OWNER-summmt ❑n OWHERAAGENT �CNR ❑CONTAACIORAGENT ❑ ARpBTECT ❑ENODJhm ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME J�`llI R �1 1.4 LICENSE NUNMEERgIVI!^� L[CFNSE E� BUS.GCp
COMPANYNAME 1 EMAM&, O4,C* a FAX yOB
srREtTADDRESS A.337 {vr+ao ALC- an.BTAry� �oSt �t P1iONE�foBSY� SX�7
AROUTECT/FNGINEER NAME LICENSE NUMBER BUS.LIC B O
COMPANY NAME' E-MAIL FAX
STREET ADDRESS ' My.STATE,ZW PHONE
USE OFwDUPIFX ❑ MD.TLFAMMY PROJECT IN WBDLJND ❑ YES PROMCTPI ❑YES IS THE BLDG AN ❑YES
BUDDING: [3 cowzmaAL URBAN DJ7F]IFA<s AREA NO FLOOD Z_OJtat?r_ - NO J IImD.FR NOME/ NO
DFSCRtPIlON OF WORK Q l�`e ��-�-tf Sed V 1 CC �`Ib M 1 •� NALTCJ' /O `�j
�\ !! e/
TOTAL VALUATION: GOQ ��' RECEIVED BY:
By my signature below,I certify to each of the following. I am dte property owner err acaborized agent to act on the property owners behalf I have read this
application and the information I have provided is correct v read the Description of Work Rod verify it is aecmate. I agree to comply with all applicable local
ordmmrces and state laws relatmg m building cams I au' aria representatives of Cupertino m enter the above-r property for inspection pu@ases.
Signature of Applicant/Agent: r/'� � Date:
SUPPLEhIENTAL;'WFORMATION REQUaED 0FF3CE USE ONLY
m OVER-THE-COUNTER
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MEPMac.fpp_2011.doc revised 06/21111