12050167 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 910 COTTONWOOD DR CONTRACTOR:NQB CONSTRUCTION PERMIT NO: 12050167
OWNER'S NAME: KODALI RAGHU R AND LAKSHMI B 2826 CICERO WAl' DATE ISSUED:05/22/2012
OWNER'S PHONE: 5107101268 SAN JOSE,CA 951.18 PHONE NO:(408)499-1946
❑ LICENSED CONTRACTOR'S
DECLARATION BUILDING PERMIT INFO: BLDG r ELECT r PLUMB r
•Q
License Class fJ Lic.H (J3b -�
_ MECH r RESIDENTIAL r COMMERCIAL r
Contractor
1 hereby affirm that 1 am liven d 4er the provisions of Chapter 9 JOB DESCRIPTION:REMOVE AND REPLACE THE KITCHEN SINK(NO OTHER
(commencing with Section 7000)of Division 3 of the Business&Professions MEP
Cade and that my license is in full force and effect. INCLUDED)
1 hereby affirm under penally 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.
I have and will maintain Worker's Compensation Insurance,m provided for by
Section 3700 of the Labor Code,for the performance of the work for which this Sq.FI Floor Area: Valualion:$300
permit is issued.
APPLICANT CERTIFICATION APN Number:36918007.00 Occupancy Type:
I certify that I have read this application and stale 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 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 score go ati per the Cupertino Municipal Code,Section
9.18.
-� Issued by: �,9PI 42Zi Date:
Signature Date_5 •�•aa�a
❑ OWNER-BUILDER DECLARATION
RE-ROOFS:
I hereby affirm that 1 am exempt from the Contractor's License Law for one of All roofs shall be inspected prior to any roofing material being installed.If a roof is
the following two reasons: installed without first obtaining an inspection,I agree to remove all new materials for
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). ALI,ROOF COVERINGS TO BE CLASS"A"OR BETTER
1 hereby affirm under penally of perjury one of the following three
declarations:
I have and will maintain a Certificate of Consent to self-insure for Worker's HAZARDOUS MATERIALS DISCLOSURE
Compensation,as provided for by Section 3700 of the Labor Code,for the 1 have read the hazardous materials requirements under Chapter 6.95 of the
performance of the work for which this permit is issued. California Health&Safety Code,Sections 25505,25533,and 25534. 1 will maintain
I have and wilt maintain Worker's Compensation Insurance,as provided for by compliance with the Cupertino Municipal Cade,Chapter 9.12 and the Health&
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 1 use equipment or devices which emit hazardous air
permit is issued. contaminants as defined by the Bay.Area.lir Quality Management District I will
I certify that in the performance of the work for which this permit is issued,I shall maintain compliance with the Cupertino Municipal Code.Chapter 9.12 and the
not employ any person in any manner so as to become subject to the Worker's Health&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 Owner or arued a enC r G2 12,forthwith comply with such provisions or this permit shall be deemed revoked. Date: S
APPLICANT CERTIFICATION CONSTRUCTION LENDING AGENCY
I 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 budding 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 of the
granting of this permit.Additionally,the applicant understands and will comply ARCHITECT'S DECLARATION
With 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: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 36918007. 00
DATE ISSUED. . . . . ... : 05/22/2012
RECEIPT #. . . . . . . . . : BS000016878
REFERENCE ID # . . . : 12050167
SITE ADDRESS . . . . . : 910 COTTONWOOD DR
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : KODALI RAGHU R AND LAKSHMI B
ADDRESS . . . . . . . . . . : 910 COTTONWOOD DR
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
RECEIVED FROM . . . . : BINH H NGUYEN
CONTRACTOR . . . . . . . : BINH H NGUYEN LIC # 32663
COMPANY . . . . . . . . . . : NQB CONSTRUCTION
ADDRESS . . . . . . . . . . : 2826 CICERO WAY
CITY/STATE/ZIP . . . : SAN JOSE, CA 95148
TELEPHONE (408) 499-1946
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 300 .00 1.00 0. 00 1.00 0.00
1BPFIXTURE NO OF FIXTURE 1. 00 9.00 0. 00 9.00 0.00
1BSEISMICR VALUATION 300 .00 0.50 0. 00 0.50 0.00
1PPERMITFE 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 139. 50 0. 00 139.50 0. 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
--- --------------- --------------------
CREDIT CARD 139.50 VISA
---------------
TOTAL RECEIPT 139.50
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
106 SEWER & WATER 202 UNDERFLOOR PLUMBING
301 ROUGH PLUMBING 302 TUB & OR SHOWER
502 FINAL PLUMBING ENERGY 506 GAS TEST
507 FINAL PLUMBING 512 FINAL HANDI-CAP
CITY OF CUPERTINO
FEE ESTIMATOR- BUILDING DIVISION
ADDRESS: 910 Cottonwood Dr DATE: 05122/2012 REVIEWED BY: Sean
APN: BP#: 'VALUATION: $300
*PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration /Addition / Repair
PRIMARY SFD or Duplex PENTAMATION 1RPFIX
USE: PERMIT TYPE:
WORK Remove and replace the kitchen sink. no other MEP included).
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Fixture or Trap 1BPFIXTURE 1 # $9
TOTALS: $9.00
s.
Mod,. Plon Check Plumb. Plan Check 0.0 hrs $0.00 F./re. Phin Check
,Lh•,:h. P,rn,h Fec: Plumb.Permit Fee: IPPERMIT lilac. Permit Fre:
olher,ifech. Insp. Other Plumb Insp. 0.0 hrs $44.00 oth<r lace. hsp.
.Ifach. b,ep. Fre: Phiurb. htvp. Fre: Islet.ln.cp. Fac•.
NOTE: This estimate does not includejees due to other Departments(i.e.Planning, Public Works, Fire,Sanitary Sewer District,School
District,etc.). Thesefees are based on lire prefindna information available and are only an estimate Contact the Det for addn7 info.
FEE ITEMS OW Resolution 11-053 E(l. 711111) FEE QTY/FEE MISC ITEMS
Plan Check Fee:
Supp/. PC Fee
PME Plan Check: $0.00
Permit Fue:
Supp/. 117sp Fee
PME Unit Fee: $9.00
PME Permit Fee: $44.00
Conan ecdon T(n.
Administrative Fee: IADMIN $41.00
Work Without Permit? 0 Yes ,(j) No $0.00
ddennced Maiming Feces:
Travel Documentation Fee: /TRA VDoc $44.00
Stronn Motion Pee: - IBSEISMICR $0.50 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $1.00
SUBTOTALS: $139.50 $0.00 TOTAL FEE: $139.50
Revised: 04/01/2012
C� Q-e✓ -h
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO,CA 95014-3255
CUPERTINO (408)777-3228•FAX(408)777-3333•buildinD(G)cuoertino.orD
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OWNER ❑ OWNER-BUILDER ❑ OWNERAGEM ❑ CONTRACTOR ❑CONrRACTOLR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT
CONTRACTOR NAME2 ( u LICENSE NU R 1 LICENSE TYPE BUS.LIC p
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DESCRIPTION OF WORK _
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