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CITY OF CUPERTINO �-t y�.
BUILDING DIVISION PERMIT V� ► W � � '
BUILDING ADDRESS: PERMIT NO.
10815 BROOKWELL DR TBD - TD BE * oc)n7nl 21
—VNER'S NAME: PERMIT ISSUE DATE
PHO :P119WWAN Wig /2899
S A CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
u0p LICENSED CONTRACTOR'S DECLARATION Job Description
m I hereby affirm that I am licensed under provisions of Chapter 9(commencing
v�Ny with Section 7000)of Division 3 of the Business and Professions Code,and my license is
in full force and effect PANEL UPGRADE
vn Z License Class Lle•N
'-�t,uj Date Contractor
ARCHITECTS DECLARATION
1 understand my plans shall be used as public records
�yU
Z. y Licensed Professional
n y 3 OWNER-BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractor's License Law for the
i p O following reason.(Section 7031.5,Business and Professions Code:Any city or county
.43 9 which requires a permit to construct,alter,improve,demolish,or repair any structure
42- prior to its issuance,also requires the applicant for such permit to rile a signed statement
that he is licensed pursuant to We provisions o(the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area Valuation
yH$ (commencing with Section 7000)of Division 3 of the Business and Professions Code)or $1200
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(5500). 36921019 . 00
❑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 Required Inspections
and Professions Code:The Contractor's License Law docs not apply to an owner of q P
property who builds or improves thereon,and who does such work himself or through his
own employees,provided that such improvements arc 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.).
LI,as owner of the property,am exclusively contracting with licensed contractors to
tntct the project(Sec.7044.Business and Professions Code:)The Contractor's Li-
cense Law does not apply to an owner of property who builds or improves thereon,and
who contracts for such projects with a contractor(s)licensed pursuant to the Contractor's
License Law.
E]1 am exe pt under Sec. B&P C r this mason
ner ER'S C PENSAI ON DECLARATIONY
I hereby affirm under penalty of perjury one of the following declarations:
❑I have and will maintain a Certificate of Consent to self-insure for Worker's Compen-
sation,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,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 arc:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars($100)
or Icss.)
I ceutifv that in the performance of the work for which this permit is issued.I shall not
employ any person in any manner so as to become subject to the Workers'Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you must
ZO forthwith comply with such provisions or this permit shall be deemed revoked.
Z 0"4 CONSTRUCTION LENDING AGENCY
E r►�- I hereby affirm that there is a construction lending agency for the performance of
(Y, the work for which this permit is issued(Sec.3097,Civ.C.)
OWi Q Lendces Name
a Lender's Address
V 0 I certify that I have read this application and state that the above information is
LL�' correct I agree to comply with all city and county ordinances and state laws misting to
O U construction.building consction.and hereby authorize representatives of this city to enter upon the
>4 OWn above-mentioned property for inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
,Hy to liabilities,judgments,costs and expenses which may in any way accrue against said City
U Z in consequence of the granting of this permit, y Date l
�
r� APPLI DERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: a iO
SOUREE ATIONS.
Re-roofs
Si rc lican n r Datt
HAZARDOUS MATERIALS DISCLOSURE Type of R)of
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
+e,Section 25532(a)? All roofs,hall be inspected prior to any roofing material being installed.
❑Yes
If a roof is installed without first obtaining an inspection,I agree to remove
Will the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants as find by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes 00
1 have read the ha72rdms materials requirements under Chapter 6.95 of the Califor-
nia Health&Safety Code,Sections 25505,25533 and 25534.1 understand do if the building
d no cu ll have a tenan t it is my responsibility to notify the upant of the
req re n ust be or to issuance of a Certificate or�gr Signature �f Applicant Date
caner ora omcd agent ! D All roof coverings to be Class" ."or better
CITY OF CUPERTINO
6 ITEMS OF 6 PERMIT RECEIPT OPERATOR: SylviaM
COPY # 1
Sec: Twp: Rng: Sub: Bl1-.: Lot:
APN . . . . . . . . : 36S,21019 . 00
DATE ISSUED. . . . . . . : 07/ 15/2009
RECEIPT #. . . . . . . . . : BS(100008195
REFERENCE ID # . . . 09(170121
SITE ADDRESS . . . . . : 10E,15 BROOKWELL DR
SUBDIVISION . . . . . .
CITY . . . . . . . . . . . . . . CUPERTINO
IMPACT AREA . . . . . .
OWNER . . . . . . . . . . . . : KRISHNAN MUSARAVAKKAM S
ADDRESS . . . . . . . . . . : 10E;15 BROOKWELL DR
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014-4608
RECEIVED FROM . . . . : MAPTIN ELECTRIC
CONTRACTOR . . . . . . . : TBI) - TO BE DETERMINED LIC # 00096
COMPANY TBI) - TO BE DETERMINED
ADDRESS . . . . . . . . . .
CITY/STATE/ZIP . . . : ,
TELEPHONE . . . . . . . .
FEE ID UNIT QUANTITY 734OUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- -- ------ ---------- ---------- ----------
1BCBSC VALUATION 1, 200. 00 1 . 00 0.00 1. 00 0 . 00
1BSEISMICR VALUATION 1, 200. 00 0 .50 0.00 0.50 0 . 00
1BUSLIC FLAT RATE 1. 00 114 . 00 0.00 114 . 00 0 . 00
1EPERMITFE FLAT RATE 1. 00 42 . 00 0.00 42 . 00 0 . 00
1ERT<200 UNITS 1. 00 42 . 00 0 . 00 42 . 00 0 . 00
1TRAVDOC FLAT RATE 1. 00 42 . 00 0 .00 42 . 00 0 . 00
-- -------- ---------- ---------- ----------
TOTAL PERMIT 241 .50 0 .00 241. 50 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CREDIT CARD 241 .50 visa
---------------
TOTAL RECEIPT 241 .50
Community Development
" 10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
�,UPE�TINO
u'1 i:n Department
Ar f
JOB AVrX,40rj
PERMIT #
� e
OWNER'S NAME: PHONE # -> — S /�y
GENERAL CONTRA OR:
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
Tile
ILI
Owner/Con actor Signat4e Dat
�at
CITY OF ('-'.'UPERTINO
CUPER�TINO GENERAL BUILDING
PERMIT APPLICATION FORM
o1;7()1z 1
APN# 2 �o 9 2 1 0 16:i ,cy) Dat'�?—z�—
Building Address: e/5 -,< -:Xze zlle e-,f, - -
t P -L
Mailing Address (if different from building address):
Are Hazardous Materials being used as part of this project? Yes 11 No
HOA: Exterior work only) Yes ❑ No ❑ If yes, provide letter from HOA
Owner'p,Xame. Phone#: _ ,
ontractor: Phone: 5 Q� 519 of 4 OrIz Of'I
��
` •- Fax:
Contractor License#:
Cupertino Business License#:
Contact: ,<,r / Phone: 3cl-
Residential
Fax:7Commercial
Job Description: '� /1 V j Z
� --
5 /�
Building Permit Info:
Bldg ❑ Elect Plumb ❑ Mech ❑
Type of Construction (Usage Class): Occupancy Type:
1-A I-B II/III/V-A ❑ II/III B, IV-HT, V-13- E
Valuatio t Square Footage:
( '
Project Size: Express ❑ Standard ❑ Large [] Major ❑
Green Building: Please complete relevant portion A the Green Building/LEED Checklist& attach it
to the application or if applicable, include in plan set& the sheet index.
Points Achieved: �+l
For help, contact Build it Green at www.builditgr(!en.org
Revised 07/14/09
CITY OF C.UPERTINO
Cin OF GENERAL BUILDING APPLICATION
CUPEI�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 3 windows)
1WINMEWSTR New Win low-structural shear B
wall/masa (includes plan ck fee)
I 1 EPERMITFEE Electrical Permit Fee E
1MPERMITFEE Mechanical Permit Fee M
1 PPERMITFEE Plumbing Permit Fee P
IELCPLNCK Stand Alone Electric Pln Ck(hourly) E
1 MECPLNCK Stand Alone Mechanical Pln Ck (hrly) M
1PLMBLNCK 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) hourl jst and alone
1BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT
TYPES
1BSEISMICR Seismic Residential B
1BSEISMIC0 Seismic Commercial B
1 TRAVDOC Travel & Documentation B
' 1BUSLIC Business License B
J
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