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12060072CITY OF CUPERTINO BUILDING PERMIT BUILDING: ADDRESS: 21604 CAS LETON ST CONTRAC'MR: ROYAL SERVICES PERMITNO: 12060072 OWN'ER'S NANIE: SI IP.KI IAR & APARNA VARANASI 2253 NIAYWOOD AVE. DA IT ISSUED: 06/13/2012 OWNF-R'S Pl IONE: 2244201814 SAN JOSE., CA 95128 11110NF. N0: (+aa) 972-2452 LICENSED CON'IRACI'OR'S DECLARATION r r r BUILDING PERMIT INFO: BLDG ELECT PLUMB 7 L Licenseclass C-761 Lic. t✓6 r r r AIECII RERESIDENTIALCOMAIFRCIAI. ��/ Contractor Date irZ— / AA 1 herebv aff;rnh that I am licensed under the provisions of Chapter 9 NINEY JOB DESCRIPTION: RGI3UII.1) 2 STORY CHIMNEY (commencing with Section 7000) of Division 3 of the Business & Professions Code and that my license is in full farce and effect. I hereby affirm under penally of perjury one of the following two declarations: I have and will mninlain a certificate of consent to self -insure for Worker's Compensation, its provided for by Section 3700 of the Labor Cade, for the performance of the work fix which this permit is issued. Sq. Ft Floor Area: Valumiun: S4900 I have and will maintain Worker's Compensation Insurance, as provided for by Section 3700 of the Labor Code, Inr the performance of the work for which this permit is usucd. APN Number: 3i620045.00 Occupanc% "type: APPLICANT CERTIFICATION I certify that I have read this application and state that the above inturmation is correct. I agree to comply with all city' and county ordinances and state laws relating to PERMIT E�C IRES I F WORK IS NOT STARTED to building construction, and hereby authorize representatives of this city enter upon the above mentioned properly for inspection purposes. (We) agree to save W1 1711, 1 UA YS OF PERMIT ISSUANCE OR indcinnil}and keep harmless the City ol'Cupenino against liabilities. judgments. 180 DAYS, ROM LAST CALLED INSPECTION. costs, and expenses which may accrue against said City in consequence of the graining o1'dhis permit Additionally, the applicant understands and will comply / ` _ — wilh all non -point source rep ulaI ions r the Cupertino Municipal Code, Section /-- Issued by:. - ' (� / L� Date: 9.18. 17 IL Signature Ualc RF. -ROOFS: ❑ OWNER -BUILDER DECLARATION All roofs shall be inspected prior to any rooting material being installed It root is installed without first obtaining an inspection, I agree to remove all new materials lit 1 hereby affirm that I am exempt from the Contractor's License Law for one of inspection. the following two reasons: L as owner of the property, or my employees with wages as their sole compensation, Signature ol'Apphcanc Date: will do the work, and the structure is not intended or offered for sale (Sce.7044, 13n S111CS5 & Professions Code) L as owner of the properly, am exclusively contracting with licensed contractors to ALL ROOF COVERINGS TO BE CLASS "A" OR BE;1-1'E ll construct the projcct(Sec.7044. Business & Professions Code). 1 hereby affirm under penalty of perjury one of the fullowing three IIA%ARDOUS MA'I E.R1ALS DISCLOSURE: declarations: 1 have read the hazardous materials requirements under Chapter 6.95 of the I have and will maintain a Certificate of Consent to self -insure for Worker's California llealth & Safety Code, Sections 25505. 25533, and 25534, 1 will maintain Compensation, as provided lit by Section 3700 of the Labor Code, for the compliance with the Cupertino Nlunicipal Code, Ch tinct- 3.12 and the I leahh & performance of the work for which this permit is issued. Safety Code, Section 25532(a) should 1 store or handle hazardous material. 1 lun'c and will maintain Worker's Compensation Insurance, as provided for by Additionally, should I use equipment or devices which emit hazardous air Section 3700 o1'the I.ahor Code, for the performance of the work for which this contaminants as defined by the Bay Area Air Quality Management District I will Cade, maintain compliance with the Cupertino Municipal Chapicr 9.12 and the permit is issued Health & Safety Code. Sections 25505, 25533, and 25534. 1 certify Thin 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 Worker's Owner or authorized aPy c ,3 ! 7� Contpcusnlion lmrs ml ' California. IL alter making this certificate ofexemption,I / Date: become subject to the Worker's Compensation provisions of the labor Code, I muss forthwith comply with such provisions or this permit shall be deemed revoked. CONS'IRUCIION LENDING AGENCY I herebyalliin That there is a construction lending agency for the performance of work's :NPPLICANT CERTIFICATION for which this permit is issued (Sec. 3097. Civ C.) I certl'y that I have read this application and stale that the above information is Lender's Name 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 Lender's Address upon The above mentioned property for Inspection purposes. (We) agree to save indemnify and keep harmless the City of Cupertino against liabilities, judgments. ARCI I fFEC'I'S DE,CLARAPION costs. and expenses which may accme against said City in consequence of the grunting of This permit Additionally, the applicant understands and will comply I understand my plans shall be used its public records, with all non -point source regulations per the Cupertino Municipal Code, Section 9.18. Licensed Professional Signature Date 3 ITEMS OF 3 CITY OF CUPERTINO PERMIT RECEIPT Sec: Twp: Rng: Sub: Blk: Lot: APN ........: 35620045.00 DATE ISSUED.......: 06/13/2012 RECEIPT #.........: BS000017059 REFERENCE ID # ...: 12060072 SITE ADDRESS .....: 21604 CASTLETON ST SUBDIVISION ....... CITY .............: CUPERTINO IMPACT AREA ....... OPERATOR: suew COPY # : 1 METHOD OF PAYMENT ----------------- CHECK TOTAL RECEIPT AMOUNT --------------- 524.50 --------------- 524.50 VOICE ID DESCRIPTION -------- ---------------------------- 101 FOUNDATION 517 FINAL CHIMNEY REFERENCE NUMBER -------------------- 21580 VOICE ID DESCRIPTION -------- ---------------------------- 312 CHIMNEY REBAR & STRAPS OWNER ............: SHEKHAR & APARNA VARANASI ADDRESS ..........: 19605 PRUNERIDGE AVE UNIT 4305 CITY/STATE/ZIP ...: CUPERTINO, CA 95014 RECEIVED FROM ....: ANTHONY XAVIEL CONTRACTOR .......: TONY XAVIEL LIC # 22767 COMPANY ..........,: ROYAL SERVICES ADDRESS ..........: 2253 MAYWOOD AVE CITY/STATE/ZIP ...: SAN JOSE, CA 95128 TELEPHONE.........: (408) 972-2452 FEE ID UNIT QUANTITY AMOUNT PD -TO -DT THIS REC NEW BAL ---------- 1BCBSC ----------------------- VALUATION 4,900.00 -------------------- - 1.00 0.00 - 1.00 0.00 1BSEISMICR VALUATION 4,900.00 0.50 0.00 0.50 0.00 1CHIMNEYRE EACH 1.00 523.00 0.00 523.00 0.00 TOTAL PERMIT ---------- -------------------- 524.50 0.00 524.50 ---------- 0.00 METHOD OF PAYMENT ----------------- CHECK TOTAL RECEIPT AMOUNT --------------- 524.50 --------------- 524.50 VOICE ID DESCRIPTION -------- ---------------------------- 101 FOUNDATION 517 FINAL CHIMNEY REFERENCE NUMBER -------------------- 21580 VOICE ID DESCRIPTION -------- ---------------------------- 312 CHIMNEY REBAR & STRAPS �� CITY OF CUPERTINO I.ID`��//JI FEE ESTIMATOR -BUILDING DIVISION NOTE: This estimate does not includejees due to other Departments (i.e. 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 addn7 info. FEE ITEMS (Fee Resolruion II -053 Eff 7/I/)U ADDRESS: 21604 Castleton DATE: 06/13/2012 APN: BP#: REVIEWED BY: gs 'VALUATION: $4,900 *PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration / Repair PRIMARY SFD or Duplex USE: la, „ 1""mir PENTAMATION 1CHIMNEY PERMIT TYPE: WORK Re- build 2 story chimme SCOPE Phunh. hf,p. Fra NOTE: This estimate does not includejees due to other Departments (i.e. 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 addn7 info. FEE ITEMS (Fee Resolruion II -053 Eff 7/I/)U 1 /,•rdr. 17mv r'h,�rk I'lruuh. /'Inn Cla•cA lJr.:. IY�m ChneR Ll. ch. P.-, wif Fee. rn,r, n, P"" n? /.'y: la, „ 1""mir Odrc" M", ln.p. Orher 1'lunth lnsp. Urhrr Elcr. /,ars. ,Ildc'h. imp. Fie: Phunh. hf,p. Fra Frc NOTE: This estimate does not includejees due to other Departments (i.e. 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 addn7 info. FEE ITEMS (Fee Resolruion II -053 Eff 7/I/)U FEE QTY/FEE I MISC ITEMS Plan Check Fee: $0.00 F-17 # $523.00 Chimney / Chimney Repair ICNIMNEYR Chimney Repair Suppl. PC Fee: Q Reg. O OT 0.0 T hrs $0.00 PME Plan Check: $0.00 Permit Fee: $0.00 Suppl. Insp. Fee:Q Reg. Q OT 0,0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 Cmoft nr'liun Tris: :Llmini.ururire Fec: Q Work Without Permit? O Yes (j) No $0.00 Advanced Plannint Fee: $0.00 Select a Non -Residential Building or Structure 0 O A 7 -nn cl Uncnmcrunlirm /,ce.s Strong, Motion Fee: IBSEISMICR $0.50 Select an Administrative Item Bide, Sids Commission Fee: IBCBSC $1.00 SUBTOTALS: $1.50 $523.00 TOTAL FEE: $524.50 Revised: 06/05/2012 ROOM 111 010-1 CITY OF CUPER,TINO JOB ADDRESS: ^(66C CSI /ef-d `^ Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone (408) 777-3228 Fax(408)777-3333 OWNER'S NAME: U -qF -AMOK I I PHONE # Qa(8(�- (GENERAL CONTRACTOR: 6Y u Ct FAX # �� I am not using any subcontractors: Please check applicable subcontractors and complete the following information: Owner ontractor S' store to 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 771 Owner ontractor S' store to 101, CUPERTINO —I NF.W CONSTRUC CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT - BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 • buildinD(�cuoertino.orG 'ION 7 ADDITION I N ALTERATION / Ti —I REVISION / DEFERRED /aolno�2 ?- ORIGINAL PERMIT N PROJECTADDRFSS i () /R f6 g APN# 3IOI 5-1 -ao -O xs t(.*e OWNERNAME PHONE 4X0 E.MAn,Shekkqr STREET ADDRESS slip CITY. STATE. ZIP FAX CONTACT NAME ^V, PHONE Lobill ONE) - iSTREET E-MAIL STREET ADDRESS,{ M� (�DO 11 I.1 d �.a� CITY, STATE. LP stL�X�sE CC" FAX ❑ OWNER ❑ OWNER -BUILDER ❑ OWNEitAGENTCONTRACTOR ❑ CONTRACTORAGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACfORN -fp/Q LICENS-NUMBER !l(tOt7q r l LICENSE TYPE C_2 Gj BUS. LIC# �U(LLS ` COMPANY NAME E-MAIL FAX . STREET ADDRESS .�^ M� W�. GV C � CITY. STATE 77P S Y�J r� Co, �I rl Zig �1'�� PHONELIP 9 q7 ARCHITECT/ENGINEEERLNNAME LICENSE NUMBER BUS. LIC # COMPANY NAME E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE DESCRIPTION OF WORK Mr0 gmv OfAI.4qo sG0 Pr- v�— EXISTING USE " PROPOSED USE CONSTR. TYPE 11 V #STORIES Z USE TYPE OCC. SQ.PT. VALUATON(S) EXLSTO AREA NEW FLOG AREA DEMO AREA TOTAL NEr.AREA qp� 1 BATHROOM KITCHEN OTHER REMODELAREA REMODELAREA REMODEL AREA PORCH AREA DECK AREA TOTALDECK/PORCHAREA GARAGE AREA: DETACH ATTACH #DWELLING UNRS: IS A SECOND UNIT ❑YES SECONWSTORY YES BRING ADDEDT []NO ADDrt70. ❑NO ❑ PRE.APPLICATION ❑IFYES,PROVIDECOPYOF IS TBLDG BEYES AN 0YS RECEIVED BY: TOTAL VALUATION: PLANNDIGAPPL# ❑NO PLANNING APPROVAL LETTER EICHLER ROME? ❑NO I L/4?00 By my signature below, I certify to each of the following: 1 am [he property owner or authorized agent to act on the p ,cperty owners behalf. I have read this application and the information I have provided is correct I e read the Description of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating to Im 'ng construction. a thoriTs representatives of Cupertino to enter the above-ide [ified property for inspection purposes. Signature of Applicant/AgenD Date: SUPPLEMENTAL ORMATION REQUIRED PLN CJRtCTCTYI' ROUTING SLE ❑ New SFD or Multifamily dwellings: Apply for demolition permit for _ existing building(s). Demolition permit is required prior to issuance of building OVER-TEW-COUNTER ]3UO.DDNG PLAN REVIRSY permit for new building. ❑ EXPRESS ❑ PLANNING PLAN REVIEW _ Commercial Bldgs: Provide a completed Hazardous Materials Disclosure El STANDARD El PUBLIC WORKS Tom if any Hazardous Materials are being used as part of this project. ❑ LARGE ❑ FMZ DEPT _ Copy of Planning Approval Letter or Meeting with Planning prior to ❑ MA]OR ❑ SANITARY SEWER DISTRICT submittal of Building Permit application. ❑ ENVIRONMENTAL HEALTB B1dgApp_ OlI. doc revised 06121/11 Im