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12060052CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 21867 SHATTUCK DR CONTRACTOR: AG CONSTRUCTION & PERMIT NO: 12060052 REMODELING OWNER'S NAME: SREEKUMAR PARMESWARAN & BEENA DAS 5292 AMELIA DR DATE: ISSUED: 06/0812012 OWNER'S PIIONF.: 4087250843 SAN JOSE, CA 95118 PHONE NO: (408) 838-2872 ❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL ❑ CODINIF.RCIAL License Class Lie. q 3 \ z L\ 1—:3 BATHROOM REMODEL 40 SQ FT Contmctae Date CSC- CSO \Z I hereby affirm that I 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: 1 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 Sq. F1 Floor Area: Valualion: $5000 performance of the work for whichthis permit is issued. I 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: 35614003.00 Occupancy Type: permit is issued. APPLICANT CERTIFICATION I cenify that I have read this application and stale 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 180 DAYS OF PERMIT ISSUANCE OR to building cons(ruclion, and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We) agree to save 180 DAYS FROM LAST CALLED INSPECTION. indemnify and keep harmless the City of Cupertino against l iabil hies,judgments. costs, and expenses which may accrue against said City in consequence of the � - '1 /� �7 Issued Date: ' - 1rri granting of this permit Additionally, the applicant understands and will comply by:.�ri%� /!�( fy 14 with all non-point source regulations per the Cupertino Municipal Code. Section RE: ROOFS: ll roofs shall be inspected prior to any roofing material being installed If a roof is 9.18. SignaqDale E7 6ua�C� �� C)%`( installed without first obtaining an inspection. I agree to remove all new materials for inspection OWNER-RIIILDER DECLARATION Signature of AppliumC 17ote: 1 hereby affirm that 1 am exempt from the Contractor's License Lew for one of the following two reasons: AL1. ROOF COVERINGS TO BE CLASS'S" OR BEITE:R I, 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 & Professions Code) I, as owner 01,01C property, am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE; construct the project (Sea 7044, Business & Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the California Ilealth & 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: Ilealth & Safrty Code, Section 25532(a) should 1 store or handle hazardous I have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally, should I use equipment or devices which emit hazardous Compensation, as provided for by Section3700 of the Labor Code, for the air contaminants as defined by the Bay Area Air Quality Management District l m perfomnce of the work for whichthis permit is issued, will maintain compliance with the Cupertino Alunicipal Code, Chapter 9.12 and I have and will maintain Worker's Compensation Insurance, as provided for by the Ilealth & Safety Cade, Sections 25505, 25533, and 25534• Section 3700 of the Labor Code, for the performance of the work for which this Owner or authorized egen • Da le: C-) (3 O L \ pemnit is issued _ I certify that in the performance of the work forwhich this permit is issued. I shall not employ any person inany manner so as to become subject to the Worker's Compensation Imus ofCalifornia. If, alter making this certificate of exemption, 1 CONSTRUCTION LENDING AGENCY become subject to the Worker's Compensation provisions of the Labor Code, I must I hereby affirm Thal fhcre 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 propeny far inspection purposes. (We) agree to save indemnify and keep harmless the City of Cupertino against liabilities, judgments, AR(:111TF.(TS DECLARATION costs, and expenses which may accrue against said City in consequence of the I 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 9.18. Signature Date "a, - CITY OF CUPEkTINO Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone (408) 777-3228 Fax (408) 777-3333 Building De artment JOB ADDRESS: 7,32, PERMIT # /�(:::;,6� OWNER'S NAME: f- PHONE # GENERAL CONTRACTOR ,4 oiv a —ofl FAX # FA I am not using any subcontractors: Signature Please check applicable subcontractors and complete the following information Date Owner/ oC n ria or Signature Date 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 Owner/ oC n ria or Signature Date � CITY OF CUPERTINO ISI FEE ESTIMATOR -BUILDING DIVISION NOTE: This estimate does not includejees due to other Departments (Le. Planning, Public Works, Fire, Sanitary Sewer District, School District, etc.). These fees are based on the oreliminary information available and are only an estimate Contact the Dept for addn'I info. FEE ITEMS (Fee Resolution 11-053 F_!f 7/1.111) ADDRESS: 21864 Shattuck Dr DATE: 06/08/2012 APN: BP#: REVIEWED BY: Sean 'VALUATION: $5,000 *PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration / Repair PRIMARY USE: SFD or Duplex filer. I".' nif Frd: PENTAMATION PERMITTYPE: 1R3SFDRE WORK Remodel downstairs bathroom 40 sq ft SCOPE Phunb. hup. Fre: NOTE: This estimate does not includejees due to other Departments (Le. Planning, Public Works, Fire, Sanitary Sewer District, School District, etc.). These fees are based on the oreliminary information available and are only an estimate Contact the Dept for addn'I info. FEE ITEMS (Fee Resolution 11-053 F_!f 7/1.111) 11.•ch. 1'1r,n C'hcrk Phmrh. Plan Check lJr,'. l'Lu, L'lurcA a 1"'J,, !':awil Fco. Phunb. Peltnh Fee: filer. I".' nif Frd: Oche, lh"h h,ay'. Olho Plumb Insp. Olber /filer. Inxp. .11. -e h. /)) 1). F,: c Phunb. hup. Fre: Efcr. Incl:, F' NOTE: This estimate does not includejees due to other Departments (Le. Planning, Public Works, Fire, Sanitary Sewer District, School District, etc.). These fees are based on the oreliminary information available and are only an estimate Contact the Dept for addn'I info. FEE ITEMS (Fee Resolution 11-053 F_!f 7/1.111) FEE QTY/FEE MISC ITEMS Plan Check Fee: $0.00 40 s.f. $588.00 Remodel, Bath (<=300 sf) /REMRESBAT Suppl. PC Fee: 0 Reg. 0 OT 0.0 1 hrs $0.00 PME Plan Check: $0.00 Permit Fee: $0.00 Suppl. Insp. Fee -.0 Reg. 0 OT F0.0Thrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 C7,nsrr'ta�liun 1m:' ,I rbniui.euntire l•',rcc 0 Work Without Permit? 0 Yes Q No $0.00 Advanced Planning Fee: $0.00 Select Non -Residential Building or Structure 0 0 A �r,mel Docmilenlnlwil Fees: Strong Motion Fee: 1BSEISMICR $0.50 Select an Administrative Item Bldg Sids Commission Fee: IBCBSC $1.00 i„ r ;y SUBTOTALS:$1.50 $588.00 TOTAL FEE:' $589.50 Revised: 06/05/2012 CITY OF CUPERTINO 3 ITEMS OF 3 PERMIT RECEIPT Sec: Twp: Rng: Sub: Blk: Lot: APN ........: 35614003.00 DATE ISSUED.......: 06/08/2012 RECEIPT #.........: BS000017031 REFERENCE ID # ... 12060052 SITE ADDRESS......: 21867 SHATTUCK DR SUBDIVISION ....... CITY ...........:.: CUPERTINO IMPACT AREA ....... OPERATOR: SylviaM COPY # : 1 METHOD OF PAYMENT ----------------- CREDIT CARD TOTAL RECEIPT : AMOUNT. -------------- 589.50 --------------- 589.50 REFERENCE NUMBER -------------------- visa OWNER ............: SREEKUMAR PARMESWARAN & BEENA ADDRESS ..........: 21867 SHATTUCK DR CITY/STATE/ZIP ...: CUPERTINO, CA 95014 RECEIVED FROM ....: A G CONSTRUCTION CONTRACTOR .......: AG CONSTRUCTION & REMODELING LIC # 32511 COMPANY ..........: AG CONSTRUCTION & REMODELING ADDRESS ..........: 5292 AMELIA DR CITY/STATE/ZIP ...: SAN JOSE, CA 95118 TELEPHONE ........: (408) 838-2872 FEE ID UNIT QUANTITY AMOUNT PD -TO -DT THIS REC NEW BAL -------- — 1BCBSC ------------- ---------- VALUATION 5,000.00 ---------- ---------- ---------- 1.00 0.00 1.00 --- — ----- .0.00 1BSEISMICR VALUATION .5,000.00 0.50 0.00 0.50 0.00 1REMRESBAT SQ FEET, 1.00 588.00 0.00 588.00 0.00 TOTAL PERMIT 589.50 0.00 589.50 0.00 METHOD OF PAYMENT ----------------- CREDIT CARD TOTAL RECEIPT : AMOUNT. -------------- 589.50 --------------- 589.50 REFERENCE NUMBER -------------------- visa CUPERTINO CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014.3255 (408) 777-3228 • FAX (408) 777-3333 • buildinG(G.cuoertino.orG I^ ,) Lp()/,q—.�k ❑ NEW CONSTRUCTION ❑ ADDITION D ALTERATION / TT ❑ REVISION / DEFERRED ORIGBNAL PERMIT # PROJECTADDRESS 2�-«6 - SFPA-1'rL .�7— APNp 5 Le V OWNER NAMEi n ��M �. Iq�j. PHO P1OO Af2'� OAS G `( oO`l EMAB. STREET ADD'S� }I �_ �r0 e�N��. L dOi KR�I 'tM�-�L CITY. SL.4TEC FAX. CONTACT NAME� N s->E f--� T2 !M-A)tot � U f -O E -MAB. STREET ADDRE 5 CIt-'/ TE P�� c4 s -'T\,q FAX ❑ OWNER ❑ OWNER-BUTLOER ❑ OWNER AGENTCONTRACTOR ❑CONTRACTORAGENT 11ARCHITECT ❑ ENGINEER 13DEVELOPER 13TENANT CONTRACT O R ^ �:, LICENSE NUMBER 0 � 1 ^0 C-•�y UCENSE TYPE y? 1� BUS. LIC 0 COPD• N IL ��`tV�_ ,\ ^ -u E -O �`'_` FAX /�� CITY. STATE Zn" STREET ADjDZ�2. riles\ �Rr��I •N ter/ q ,meq �p ARCHTTECT/ENGRNEER NAME LICENSE NUMBER BUS. UC f COMPANY NAME E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE DESCRIPTION OF EXISTPI USE PROPOSF,o USE /JGF CPE PE .V/ 0STOR USE TYPE OCC. SQ.FT. VALUATION (S) EXISTG AREA NEW FLOOR AREA DEMO AREA TOTAL NET AREA f BATHROOM�))JJJj��I� KITCHEN OTHER. REMODEL EA AR!� RE'NODEL AREA REINOOEL AREA PORCH AREA DECK AREA TOTAL DECKIPORCHARFA GARAGE AREA: DETACH ATTACH I a DWELLING UN11S: ISASECONDUNTT YES I SECONm STORY ❑YES BEING ADDED? []NO ADDITION' []NO PRE -APPLICATION ❑YES LFYES,PROVIDE COPYOF ISTBBBMGAN ❑YES RECEIVED Y: TOTAL VALUATION: ANNGMPLO ❑NO Pt.WNINO MP0.0`/AL IJ:I'IFR PLDI EICBLERHOMEt ❑NO 7� / ^l,0 By my signature below, I certify to each of the following: I am the property owner or authorized agent to act on the pq:perty awner's behalf. I have read this application and the information 1 have provided is correct. 1 have read the Description of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating to building coostru Orin es of Cupertino to enter the above-identilied property for inspection purposes. Signae of Applitant(Agent Date: m ed tur C) CJ ZC> k L, SUPPLEMENTAL INFO TION REQUIRED PLAN CHECK TYPE ROUTING SLIP OVER-THE-COUNTER q��/'' y9, eUILDNAN G PLREVIEW ( . New SFD or Multifamily dwellings: Apply for demolition permit for existing building(s). Demolition permit is required prior to issuance of building permit for new building. ❑ EXPRESS ❑ PLANNING PLAN REVIEW Commercial Bldgs: Provide a completed Hazardous Materials Disclosure ❑ STANDARD ❑ PUBLIC WORKS To—mi if any Hazardous Materials are being used as part of this project ❑ LARGE ❑ FIRE DEPT Copy of Planning Approval Letter or Meeting, with Planning prior to ❑ w OR ❑ SANITARYSEWER DISIIUCT submittal of Building Permit application. ❑' ENVIRONWffNTAL HEALTH BldgApp_2011. doc revised 06/21/11 O `3 ��2'. COMMUNITY DEVELOPMENT DEPARTMENT BUILDING DIVISION - CUPERTINO� APPROVED set of plans and specifications MUST be kept at the jo site during construction. It is unlawful to make any changes or alterations on same, or to deviate I 9refrom, without approval from the Building Official. he stamping of this plan and specifications SHALL NOT be held to permit or to be an approval of the violation of any provisions of any City Ordinance or State Law. 0Y ��c/tN ATG PERMIT NO. LZC1-P t FXivZU-- 1 -- RECF,IVF,D JUN 08 2012 30 -- Y: AiR �a)} h4dlC� 1 REVIEWE r� �%Gn/OX/(7C TCcTU zev1ewed By: W1)D+J JUN 082012 v .. N '�