12070058 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10475 BYRNE AVE CONTRACTOR:POTLURI SRINIVAS AND PF.RMITNO: 12070058
BULLIAMMAYI
OWNER'S NAME: POTLURI SRINIVAS AND BULLIAMMAYI 10475 BYRNE AVE DATE. ISSUED:07/09/2012
OWNER'S PHONE: 4082421430 CUPERTINO,CA 95014 PIIONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTIONRESIDENTIAL 11 CONIMERCIAI.
License Class Lic.N BATHROOM REMODEL 90 SQ RE TILE SHOWER
Contractor Date
-
I 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.
1 hereby affirm under penalty 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 whichthis permit is issued. Sq.Ft Floor Area: Valuation:$9000
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:35712039.00 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 180 DA 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 DAYS FRO T CALLED INSPECTION.
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the
Date:
granting of this permit. Additionally,the applicant understands and will comply Issued by:
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18.
RF:ROOFS:
Signature Dale All roofs shall be inspected prior to any roofing material being installed.If a roof is
installed withaW first obtaining an inspection,I agree to remove all new materials for
inspection.
OWNER-BUILDER DECLARATION
Signature of Applicant Date:
I hereby affirm that 1 am exempt from the Contractor's License Law for one of
the following two reasons: AL1.ROOF COVERINGS TO BE CLASS"A"OR BETTER
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& Professions Code)
I,as owner of the property,am exclu9vely contracting with licensed contractors to IIA%NRDOUS MATERIALS DISCLOSURE
construct the project(Sec.7044,Business&Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the
California Health&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 Cole,Chapter 9.12 and the
declarations: Health&Safely Code,Section 25532(a)should I store or handle hazardous
1 have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally,should I use equipment or devices which emil hazardous
Compensation,as provided for by Section 3700 of the Labor Code,for the air contaminants as defined by the Bay Area Air Quality Management District 1
performance of the work for which this permit is issued. will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safely Cade,Sections 25505,25533,and 25534.
Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agent: I nDale:
permit is issued.
1 certify that in the performance of the work for which this permit is issued.I shall
not employ any person many manner so as to become subject to the Worker's
Compensation laws of Cali lomat- If,after making this certificate of exemption,I CONSTRUCTION LENDING AGENCY
become subject to the Worker's Compensaion provisions of the Labor Code,I must I hereby affirm that there 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 cent fy 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 stale 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
indemnify and keep harmless the City of Cupertino against liabilities,judgments, ARCHITECT'S 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
CONSTRUCTION PERMIT APPLICATION �cj
B
is COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION l
10300 TORRE AVENUE•CUPERTINO, CA 950143255 n �
(408)TT7-3228 • FAX(408)T77-3333 • buildinD(DD_cuoertino.orc \
CUPERTINO
❑NEW CONSTRUCTION ❑ ADDITION fil ALTERATION/TI ❑ REVISION/DEFER-FED ORIGINAL?EF.NQI':Y
PROJECT.ADDRFSS IDl.�`1Z ��I N P,-V (� AFNx 3 —' -1 ( 2 C: i
OWNER NAMEtj V L L 1 n IM M O U PHONE LIC 5 '21,t 2- L131J E-MA.'L
S r� I N I4�H l lot ,t br D `tU 11 I
STRE.°T ADDRESS 1 f .,/ �L. v�.l /TttQ CITY. STATE.ZIP /�p, 1�M U FAX .
CONTACT NAME J A'lP'1 ) L- PHONE L(u b' - SU6 E-MAII.
S-M.EET ADDRESS CITY,STATE. ZIP FAY
OWNER 8 OWNER-BUILDER ❑ OWNERACENT ❑ ooNTRACroR ❑CONTRACT OR AGENT ❑ ARCHITECT ❑ENoLNER ❑ DEv:JnPSR ❑ TENANT
CONTRACTOR NAME `� ([��..1 I L LICENSE NUMBER T_CENSEE TYPE BL'S.LIC N
COMPANY NAME E-MAE. FAX .
STREET ADDRESS CTI1',STATt IIP PHONE r G
`il 6
ARCHMECUENGINEEt NAME LICENSE NUMBER BUS.UC4
COMPANY NAME E-MAB. FAX
STREET ADDRESS CITY,SATE,ZIP ?HONE
DESCRIPTION OF WORK
oJI-1 w -VILA
GU E PROPOSED USE CONSILTYPE a5ro
,U-Q USE TYPE OCC sq., VALUAIlON(S)
E)GSTO NEv/FL OR DEMO W%
AREA AREA AREA 9 W%.E1
BATHROOM C7IE1I OTHER
REMODELAREA aEMODELAaEA, REMODELAREA
PORCH ARTA DECK AREA TOTAL DECR'/PORCH AREA GAR.\GE AREA T NTACH
ATTACH
p DWEL GUNITS: ISA SECOND UNrr YFS SECOf.-D STORY \\--Y
eFJNG ADD®' 0 ADDITION! \OES
NO
PRE.APPL'CATION ❑YES TYES,PROVIDECOPYOF IHTBEBLDCAN Y RECEVED BY: T VALUAT: N:
PLANNING ADPL O'RNO PLANNINOAPFROVALLETTER ECMJMIIOMHr NO
By my signature below,I cer=y m each of due',bIlowing: I am the property owner or authorized agent m act on:he prppetry owner's benal C1 have read this
application and the informazior I have provided is content I have read the Description of Work and verify it is accurate. I ageW comply With all applicable local
ordinances and some laws relating to building constructim I authorize representatives of Cupertino to enter rhe above-identified pmry oefor inspection proposes.
Signature of ApplicauzdAgint: Date: /
2L 9 120 (;�-
SUPPLEvMYrALINFORMATIONREQUaED PLAN CHECK TYPE ROUrLNGSLrP
Nev,SFD or Multifatrdly dwellings: Apply for demolition permit for ) oven-=<ocm'lDt ❑ HrmDINe PLAY aEvmw
existing building(s). Demolition permit is required prior to issuance of building -
permit for new building. ❑ EXPREss _ ❑ PLANNING P"N REVIEW
_Commercial Bldgs: Provide a completed Hazardous Materials Disclosure ❑ sGNDARD ❑ PUBLIC WORKS
form if any Hazardous Materials are being used as part of this project.
❑ LARGE ❑ FIRE DEPT
_Copy of Platming Approval Letter Or Meeting with Planning prior to ❑ xuoR C1 sANrrARv sewve DrsrRILT
Submittal of Building Permit application.
❑ ENVEROMNUENTAL BEA r.TH
BldgApp_2011.doc revised 06/21/11
1
JUL 0 y 2012
BY
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