09010028 CITY OF CUPERTINO
BUILDING DIVISION PERMIT � I�t :
BUILDING ADDRESS: PERMIT NO.
OWNER'S NAME: PERMrr ISSUE DATE
O SANOW 0 8 0 9 CONTROL NO.
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
UPGRD PANEL FM 100AMP TO
o c LICENSED CONTRACTOR'S DECLARATION 2 0 DAMP Job Description
U I hereby affirm that I am licensed under provisions of Chapter 9(commencing P
z t, with Section 7000)of Division 3 of dee Business and Professions Code,and my license is
�<y in full force and effect.
? License Class Lic.N
Date Contractor
ARCHITBCPS DECLARATION
U1 understand my plans shall be used as public records
yLicensed Professional
0 3 OWNER-BUILDER DECLARATION
rA
ai<f I hereby affirm that I am exempt from the Contractor's License Law for the
in O following reason.(Section 7031.5,Business and Professions Code:Any city or County
4 m� which requires a permit to construct.alter,improve,demolish,or repair any structure
y Z prior to its issuance.also requires the applicant for such permit to file a signed statement
=G that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area Valuation
(commencing with Section 7000)of Division 3 of the Business and Professions Code)or
y .. that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
not more than five hundred dollars($500). p y yp
0 I,as owner of the property,or my employees with wages as their soic compensation,
will do the work and the structure is not intended or offered for sale(Sec.7044,Business
and Professions Code:The Contractors License Law does not apply to an owner or Required Inspections
property who builds or improves thereon,and who does such work himself or through his
own employees,provided that such improvements are not intended or offered for sale.if.
however,the building or improvement is sold within one year of completion,the owner-
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
l owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business and Professions Code:)The Contractor's u-
cense Law does not apply to an owner of property who builds or improves thereon,and•
who Contra is fo such projects with a contractor(s)licensed pursuant to the Contractors
License Law.
0 1 am ex t under Sec. B tit P C for s reason
Owner Date V
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
1 have and will maintain a Certificate of Consent to self-insure for Worker's Compen-
.don,as provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued.
0 I have and will maintain Worker's Compensation Insurance,as required by Section
3700 of the Labor Code,for the performance of the work for which this permit is issued
My Worker's Compensation Insurance carrier and Policy number am:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is Cor one hundred dollars($100)
or Ices)
I certify that ithe ormance of the work for which this permit is issued,I shall not
employ any pc n i y manner so as to become subject to •Wo Compensation
Laws of Califo i
Applicant
NOTICE TO I1 NT:If,after making this Certificate of Exemption,you should
become subjecg Ed the Worker's Compensation provisions of the Labor Code,you must
,J 0 forthwith comply with such provisions or this permit shall be deemed revoked.
z 0-4 CONSTRUCTION LENDING AGENCY
[-+►�� I hereby affirm that theft:is a construction lending agency for the performance of
(Y, the work for which this permit is issued(Sec.3097,Civ.C.)
Ow.0 Lender's Name
] Lender's Address
U Q I certify that I have read this application and state that the above information is
(y correct.I agree to comply with all city and county ordinances and state laws relating to
0 building construction,and hereby authorim representatives of this city to enter upon the
Uabove-mentioned property for inspection purposes.
PA (We)agree to save,indemnify and keep harmless the City of Cupertino against
rFr to liabilities,udgments.costs and expenses which may in any way accrue against said City
()z in con nce of
the granting of this permit
APP NT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOU REGULATIONS. �k&-a
Re-roofs
Signalttl
f Applicant/ConLrwtor Date /-
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
the applicant or future building occupant store or handle hazardous material
at defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
❑Yex
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
t hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
,trice?
0Yes 6]No
I have read the harardous materials requirements under Chapter 6.95 of the Califor-
nia Hcalth&Saft Cade,Sections 25505,25533 and 25534.1 understand that ihho building
does noturtc have a tenant.that it is my responsibility to notify dee occupant of the
requiremich must be met prior to issuance of a Certificate o T gancy, Signature of Applicant Date
Go All roof coverings to be Class"{``or better
Owner o a rized agent Date
CITY OF CUPERTINO
5 ITEMS OF 5 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec : Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . . 36919028 . 00
DATE ISSUED. . . . . . . : 01/08/2009
RECEIPT # . . . . . . . . . . BS000006925
REFERENCE ID # . . . : 09010028
SITE ADDRESS . . . . . : 850 CANDLEWOOD DR
SUBDIVISION . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . .
OWNER KANNAN DEVARAJAN
ADDRESS 850 CANDLEWOOD DR
CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-4653
RECEIVED FROM . . . . : KANNAN DEVARAJAN
CONTRACTOR WEI WANG LIC # 29057
COMPANY UW CONSTRUCTION INC
ADDRESS 847 SEVELY DR
CITY/STATE/ZIP . . . : MOUNTAIN VIEW, CA 94041
TELEPHONE (408) 687-8282
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ---
1BCBSC VALUATION 1, 000 . 00 1. 00 0 . 00 1 . 00 0 . 00
1BSEISMICR VALUATION 1, 000 . 00 0 . 50 0 . 00 0 . 50 0 . 00
1EPERMITFE FLAT RATE 1 . 00 40 . 79 0 . 00 40 .79 0 . 00
1ERT<200 UNITS 1 . 00 40 .79 0 . 00 40 . 79 0 . 00
1TRAVDOC FLAT RATE 1 . 00 40 . 79 0 . 00 40 .79 0 . 00
---------- ---------- ---------- ----------
TOTAL PERMIT 123 . 87 0 . 00 123 . 87 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CREDIT CARD 123 . 87 VISA
---------------
TOTAL RECEIPT 123 . 87
C)
.:.,.. CITY OF CUPERTINO
CUPEk INO GENERAL BUILDING
PERMIT APPLICATION FORM
APN # Date: t
.3
Building Address:
(f SCR;i A,v C A - 7y o t�
Mailing Address (if different from building address):
Owner's Name: j� J-,,, � &V-9 R Phone#: 72-5-- eL/
Contractor: P lV CZ N,, 1 U C ;1 U 1V Phone: 4 v 6J 7- S'z Y z-
JAS o i-! /vo N L, Fax:
Contractor License#:
Cupertino Business License#:
Contact: q t�,� �v; ,� Phone: 4 c�'-f d 7 _PZ-9 z-
Fax:
Residential ❑' Commercial El
Job Description:
Building Permit Info:
Bldg ❑ Elect KY Plumb ❑ Mech ❑
Type of Construction(Usage Class): Occupancy Type:
1-A, 1-B ❑ II/III/V-A ❑ IUIII B, IV-HT, V-B li
Valuation: l� Square Footage:
Project Size: Expres Standard ❑ Large ❑ Major ❑
Green Building: Please complete relevant portion of the Green Building/LEED Checklist & attach it
to the application or if applicable, include in plan set& the sheet index.
Points Achieved: !„r
For help, contact Build it Green at www.buildit reen.or
Revised 10/20/08
` CITY OF CUPERTINO
CITY of GENERAL BUILDING APPLICATION
CUPE(�TINO
FEE SCHEDULE
Quantity/Sf Fee ID Fee Description Fee Permit Type
Group 1GENRES or
1GENCOM
1STUCOAP Stucco Applications (up to 400 sf) B
additional stucco application
1 WINREP Replacement windows/sliding glass B
door (ea 8 windows)
1 WINMEWSTR New Window-structural shear B
wall/masonry (includes plan ck fee)
1 EPERMITFEE Electrical Permit Fee E
1MPERMITFEE Mechanical Permit Fee M
1 PPERMITFEE Plumbing Permit Fee P
1 ELCPLNCK Stand Alone Electric Pln Ck (hourly) E
1 MECPLNCK Stand Alone Mechanical Pln Ck (hrly) M
1 PLMBLNCK Stand Alone Plumbing Pln Ck (hrly) P
1 STPLNCK-(3 Hr Min Standard Plan Check (when no E/M/P) B
when not over counter) hourly-stand alone
/ 1BSEISMICR Seismic Residential B
1 BSEISMICO Seismic Commercial B
1 TRAVDOC Travel &Documentation B
1 BUSLIC Business License B
5 of 5
.In oor rr ualrty an mrs es INPUT Resources Enugy IAQ/Health
1.Use Low/No-VOC Paint 1 IAQ/Health pts y=yes 0
2.Use Low VOC,Water-Based Wood Finishes 2 IAQ/Health pts y=yes 0
3.Use Low/No VOC Adhesives 3 IAQ/Health pts y=yes 0
4.Use Salvaged Materials for Interior Finishes 3 Resource pts y=yes 0
5.Use Engineered Sheet Goods with no added Urea
Formaldehyde 61AQ/Health pts y=yes 0
0
6.Use Exterior Grade Plywood for Interior Uses 1 IAQ/Health pts y=yes
7.Seal d Exposed Particleboard or MDF 4 IAQ/Health. pts y=yes 0
8.Use FSC Certified Materials for Interior Finish 4 Resource pts y=yes 0
9.Use Finger-Jointed or Recycled-Content Trim 1 Resource pts y--yes 0
10.Install Whole House Vacuum System 3 IAQ/Health pts y=yes 0
1 1 1
N.Flooring
1.Select FSC Certified Wood Flooring 8 Resource pts y=yes 0
2.Use Rapklly Renewable Flooring Materials 4 Resource pts y=yes 0
3.Use Recycled Content Ceramic Tiles 4 Resource pts y=yes 0
4.Install Natural Linoleum in Place of Vinyl 5 IAQ/Health pts y=yes 0
5.Use Exposed Concrete as Finished Floor 4 Resource pts y=yes 0
6.Install Recycled Content Carpet with Low VOCs 4 Resource pts y=yes 0
1 t 1
Total Points Available: 1 1401 1301 57
Total Points Project Received: 01 0 0
c
G:data/progs/greenbuiidingguidelines/remodelers/greenpointsfinal212.04protected.xls
OWNER-BUILDER VERIFICATION
1. (Check one) I or my immediate family(parent,spouse or child)will perform:
A. _ 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
e47, 0/- 4,J-6,c7-d2dZ
�1 cti LvNS i f'i�cT!u iv
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 (r ve side).
Property Owner's Signature: Date: ° 7
Job Address: Permit#
Any changes to the information provided on this form shall be submitted to the City of Cupertino Build
Department.
Community Development
10300 Torre Avenue
acay
Cupertino CA 95014
Telephone(408)777-3228
OF Fax(408)777-3333
';UPEkTINO
Buildin De artment
JOB ADDRESS: v 0� 31 G� 6voo P �l- PERMIT #
(1) -4
CvPEi��r,�c C'R - 9.s"/ �� V� V
OWNER'SNAME: KRrv1vr4ti PHONE # t,uS-7Z s-(�z
GENERAL CONTRACTOR: JAS:.nr h1,1 ti 4 FAX #
G Lv R N s 9 t, c,r UFd
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following information:
SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets &Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring: Carpeting
Linoleum/ Wood
--Glass,/ Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
T'
°
Owner/Contractor Signature Date