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12060054 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10701 CASTINE AVE CONTRAC"1'OR:SOMA EDUNURI PERMIT NO: 12060054 OWNER'S NAME: SOMA 17DIJNURI 10701 CASTINE AVE DATE. ISSUED:06/08/2012 OWNER'S PI[ONE: 4084251425 CUPERTINO,CA 95014 PIIONF.NO: ❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIALU COMMERCIAL❑ License Class Lic.0 POOL DEMO 342 SQ FT AT SFDW L Contractor Dale 1 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 cerificate 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 whichthis permit is issued. Sq.FI Fluor Area: Valuation:$1000 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:32643039.00 Occupancy Type: permit is issued 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 comply with all city and county ordinances and state laws relating WITHIN 1 D YS 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 DAYM LAST CALLED INSPE N. indemnify and keep harmless the City of Cupertino against liabilities,judgments. costs,and expenses which may accrue against said City inconsequence of the 7 L granting of this permit_ Additionally,the applicant understands and will comply Issued by: '/ — Date: 2, with all non-point source regulations per the Cupertino Municipal Code.Section 9.18. RE ROOFS: Signature Date All roofs shall be inspected prior to any'roofing material being installed If a roof is installed without first obtaining an inspection,I agree to remove all new materials for 7. inspection. OWNER-BUILDER DECLARATION hereby affirm That 1 am exempt from the Contractor's License Law for one of Signature of Applicant: Date: the following two reasons: AL1.ROOF COVERINGS TO BE CLASS"A"OR BETTER I,as owner of the property,or my employees with wages as their sole comp risation, will do the work,and the structure is not intended or offered for sale(Sec.7044, Business&Professions Code) 1,as owner of(he property,am exclusvely contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE construct the project(Sce.7044,Business&Professions Code). 1 have read the hazardous materials requirements under Chapter 6.95 of the California Health&Safely Code,Sections 25505,25533,and 25534. 1 will 1 hereby affirm under penally of perjury one of the following three maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the declarations: Ilealth&Safety Cade,Section 25532(x)should 1 store or handle hazardous I have and will maintain a Certificate of Consent to self-insure for Workers malerial. Additionally.should 1 use equipment or devices which emir hazardous Compensation,as provided for by Section3700 of the Labor Code,for the air contaminants as defined by the Ba% Area Air Quality Management District 1 performance of the work for whichthis permit is issued. will maintain compliance with the Cuperlino A92icipal Code,Chapter 9.12 and I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sections 25 ., ,and 25534. Section 3700 of the Labor Code,for the performance of the work for which this ___ _ _ permit is issued Owner or authorized➢g`ent: _-Deter I certify that in the performance of done work for which this permit is issued,I shall not employ any person inany manner so as to become subject to the Worker's Compensation Imus of Cafifomu. If,after making this certificate of exemption,I CONSTRUCTION LENDING.AGENCY become subject to do Worker's Compensation provisions of the Labor Code,I must I hereby affirm that there is a construction lending agencyfor the performance of forthwith comply with such provisions or this permit shall be deemed revoked. work's for which(his peril 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 ,ARC:III"fF.C7"S DECLARATION indemnify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may acme against said City in consequence of the I understand my plans shall he used as public records, granting of this permit.Additionally,the licant understands and will comply with all non-point source source regulations—r��Cupertino Municipal Code,Section Licensed Professional 9.18. Signature h Date— /� OWNER-BUILDER DISCLOSURE FORM COMMUNITY DEVELOPMENT DEPARTMENT"BUILDING DIVISION 10300 TORRE AVENUE "CUPERTINO. CA 95014-3255 CUPERTINO (408)777-3228"FAX(408)777-3333"buildina(okupertino.oro Dear Property Owner(s): An application for a building permit has been submitted in your name listing yourself as the builder of the property improvements specified at: SITEADDRESS ?01 / ? A 'iVk_t— /,1 .� APN BP# OWNER NAME D . U (/ IL ADDRESS DESCRIPTION OF WORK: VWl Y Y'/ / We are providing you with an Owner-Builder Acknowledgment and Information Verification Form to make you aware of your responsibilities and possible risk you may incur by having this permit issued in your name as the Owner-Builder. We will not issue a building permit until you have read, initialed your understanding of each provision,signed,and returned this form to us at our official address indicated. An agent of the owner cannot execute this notice unless you, the property owner, obtain the prior approval of the permitting authority. OWNER'S ACKNOWLEDGMENT AND VERIFICATION OF INFORMATION (DIRECTIONS:Please read and initial each statement below to signify you understand or verify this information.) 4±1. 1 understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner- Builder" building permit that erroneously implies that the property owner is providing his or her own labor and material personally. 1, as an Owner-Builder, may be held liable and subject to serious financial risk for any injuries sustained by an unlicensed person and his or her employees while working on my property. My homeowner's insurance may not provide coverage for those injuries. I am willfully acting as an Owner-Builder and am aware of the limits of my insurance coverage for injuries to workers on my property. 4LI understand building permits are not required to be signed by property owners unless they are responsible for struction and are not hiring a licensed Contractor to assume this responsibility. 3. 1 understand as an"Owner-Builder" I am the responsible party of record on the permit. I understand that I may protect myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her name instead of my own. el4. 1 understand Contractors are required by law to be licensed and bonded in California and to list their license nu bers on permits and contracts. 5. 1 understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the total value of my construction is at least five hundred dollars ($500), including labor and materials, I may be considered an "employer" under state and federal law. d6. I understand if I am considered an "employer" under state and federal law, I must register with the state and federal government,withhold payroll taxes, provide workers' compensation disability insurance, and contribute to unemployment compensation for each"employee." I also understand my failure to abide by these laws may subject me to serious financial risk. 7. 1 understand under California Contractors' State License Law, an Owner-Builder who builds single-family residential structures cannot legally build them with the intent to offer them for sale, unless all work is performed by licensed subcontractors and the number of structures does not exceed four within any calendar year, or all of the work 1is p ormed under contract with a licensed general building Contractor. 8. 1 understand as an Owner-Builder if I sell the property for which this permit is issued, I may be held liable for any financial or personal injuries sustained by any subsequent owner(s)that result from any latent construction defects in the workmanship or materials. OwnerBuilderForm 2010.doe revised 04114110 �f• d9. I understand] may obtain more information regarding my obligations as an "employer"from the Internal Revenue Service, the United States SmallBusiness Administration, the California Department of Benefit Payments, and the California Division oflndustrial Accidents. 1 also understand I may contact the California Contractors' State License Board (CSLB)at 1=800321=CSLB (2752)or www.cslb.ca.gov for more information about licensed con actors. It 0. 1 am aware of.and consent to an Owner-Builder building permit applied for in my namecand understand that am the party legally and financially responsible for proposed construction activity at the site address listed above. 11. 1 agree that, as the party legally and financially responsible for this proposed construction activity, I will abide 1applicable laws and requirements that govern Owner-Builders as well as employers. 12. 1 agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the information I have provided on this form`Licensed contract6m bee regulated by laws designed to protect the public. If you contract with someone who`does`not haven license, the Contractors'State License Board may be unable to assist you with any financialloss you maylsu"stain''as a result of a complaint. Your only remedy against unlicensed Contractors may be in civitcourt. It is,also important for you to understand that if an unlicensed Contractor or employee of that individual or•.firm'is irijured while working on your property, you may be held liable for damages. If you obtain a permit as Owner-Builder andWshito hire Contractors, you will be responsible for verifying whether or not those Contractors areproperlydicensed and the status of their workers'compensation insurance coverage. CONSTRUCTION LENDING+AGENCY (DIRECTIONS:Please complete the following'construction lending agency information.) I hereby affirm that there,is a construction lending agency for the performance of the work for which this permit is issued (Sec 3097 Civ.) Lender Name: Lender Address: Before a building permit can,be issued, this:forni must be completed and signed by the property owner and returned to the agency responsible for issuing'the permit. Note:A copy of the property owner's drivers license, form notarization, or other ven'ficatiori.acceptableto ti city may be required to be presented when the permit is issued to verify the property owners signature. Property Owner's Signature: .. Date: -------------------------- ---------------- (NOTE: The following Authorization Form is required to be completed by the property owner only when designating an agent of the property owner to apply for a construction permit for the Owner-Builder). AUTHORIZATION'OF'AGENT TO ACT ON PROPERTY OWNER'S BEHALF Excluding the Notice to Property Owner, the execution of which I understand is my personal responsibility, I hereby authorize the following person(s)to act as my agent(s)to apply for, sign, and file the documents necessary to obtain an Owner-Builder Permit for my project. Scope of Construction Project(or'Description of Work): Project Location or Address: Name of Authorized Agent: Tel No Address of Authorized Agent: I declare under penalty of perjury.that I am the property owner for the address listed above and I personally filled out the above information and certify its•accuracy. Note:A copy of the property owner's driver's license, form notarization, or other verification acceptable to the city may be required to be presented when the permit is issued to verify the property owners signature. Property Owner's Signature: Date: • �� OwnerBuilderForm_2010.doc revised 04114110 CITY OF CUPERTINO 3 ITEMS OF 3 PERMIT RECEIPT OPERATOR: SylviaM COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN . . . . . . . . : 32643039. 00 DATE ISSUED. . :. .. . : 06/08/2012 RECEIPT #. . . . . . . . . : BS000017034 REFERENCE ID: # . . . : 12060054 SITE ADDRESS. . . . . . : 10701 CASTINE AVE SUBDIVISION . . . . . . . CITY . . . . . . . . . . . . . : CUPERTINO IMPACT AREA . . . . . . . OWNER . . . . . . . . . . . . : SOMA EDUNURI ADDRESS 10701 CASTINE AVE CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM . . . . : SOMA EDUNURI CONTRACTOR . . . . . . . : LIC # *OWNER* COMPANY . . . . . . . . . . : SOMA EDUNURI ADDRESS . . . . . . . . . . : 10701 CASTINE AVE CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 TELEPHONE . . . . . . . . : 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 1DEMOPRE EACH 1. 00 300. 00 0.00 300 .00 0 .00 TOTAL PERMIT 301.50 0 .00 301 .50 0. 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CREDIT CARD 301.50 AX --------------- TOTAL RECEIPT 301.50 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- -- --------------- -------------- 704 DEMO NK ,,.,;, � N �1 °O /L PLOT PLAM �1 =Ca � OATE PLANNING DEPT, a® DATE \l �LIM ra r. .. DEPT: o ��e J 'oy t SWIMMING.POOL / SPA PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION 10300 TORRE AVENUE •CUPERTINO, CA 95014-3255 S P CUPERTINO (408)777-3 2jB• FAX(408)777-3333 •buildinD(Mcuoertino.orG IZb� � PRO=ADDRESS (XPN 9 32, IP LA 1 3 I_3 / OWNER NAME Soma ED V N L) PHONE LkoO-I -Jj.I-��413---MAR .SvO i1jr STREET ADDRESS 1D70� /.��1_ ✓�`D/-� 1�t6LIG_ CITY,SfAiE ZIP FAA (/ I /- X10 -cq �/l�y FAX (J CONTACT NAME l ^^C'(�� . t�1!/✓"` ' 1 N r I- PHDNE (.t e Q'�-(,�f( x) -1/-� E-M"a' STREET ADDRESS /��^J `'' _ /�,/� CITY,STATE, ZIP FAX OWNER ❑ OWNER-BUILDER .❑ OWNERAGENT ❑ CDNTRACTOR ❑CONBM.TOR AGENT Y❑r ARCHITECT L/❑�ENGNEER ❑ DEVELOPER ❑ TENANT CONIAACIORNAME LICENSE NUMBER LICENSETYPE BUS.LICA COMPANY NAME E-MAIL FAX STREET ADDRESS CTIY,SEAT$ZIP PHONE ARCKrTEC"rAFN. GINEER NAME LICENSE NUMBER BUS.LIC a COMPANY NAME E-MAIL FAX STREET ADDRESS CrrY,STATE,ZIP PHONE DESCRIPTION OF WORK USE OF 3A SFD or Duplex ❑ Multi-Family TYPE MATERIALTYPE(CODE) AREA (SQ.FT.) VALUATION(S) STRUCITIRE: ❑ Commercial POOL 500 ISPA MATERIAL TYPE CODES- 1 V -Li VNYL-LVED SPA UI •V /i F - FIBERGLASS DEMO G - GUMTEIS N + . P - PREFABRICATED �'RECEDIm H_'� � TS��s ��+, TOTAL AyL�(v 0Y"'waerllkQYYi'4.ahY.xY .-`�I.sLfi-i�; UL---/ By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on the property owner's behalf. I have read this application and the information I have provided is correct 1 h veead the Description of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating to building construction. / ooze rue des of Cupertino to enter the above-ide 'fled property for inspection purposes. Signature of Applicant/Agent: Date: - 'J SUPPLEMENTAL[NFO REQUIRE A—ss '&% Commercial or Multi-Family Buildings with Public Swimming Pools Department of Environmental Health approval required. ;t�,Srvetr�-cro r 'a`trbDavc�E � rt Ir1rsP' uv�Dda�w� .-a• . >��-' - '4 .��- �� pF- �<+ eEOH Y��wO�R.KSyDBP.rI ,��'i ��+Y... �� :Yr-�^Jr'•1'-rte.=mac I�raac�rx., �t.;,�cs�t EctvDtotvTrflruF�AeTIrr��-�--'� .`l�`�-Mh]OA��vv.aa r 'F+�-T '^��{ta1'XRY SEWEROISIAICi,.,t.v: Swim 000Upp_2011-doc revised 03/16/11