12080006 CITY OF CUPERTINO BUILDING PERMIT
BIJILDING ADDRESS: 10205 POTTERS IIATCFI CMN CONTRACTOR:BROTHERS HOME PERMITNO: 12080006
IMPROVEMENT
O\\'NI.R'S NAME: SURI JAIPRARASII AND BALIJEPALLI SAT 2510 DOUGLAS BLVD DATE ISSUED:081022012
OWNEIR'S PlIO,NE: 4083738323 ROSEVILLE,CA 95661 PII01NENO:(408)295-0680
❑ LICh:NSI?U C(bNI'IL\CI'Okp'SpD ItCfLInR.VI'10\ BUILDING PERMIT INFO: BLDG r ELECT r PLUDIB r
License Clas_6 C`� Lie 9 l ! V r r r
PIECJI RESIDENTIAL COMMERCIAL
Contractor Datc dl—Z !/
I herebyaffinn that l am licensed under the provisions of Chap(er') •106 DESCRIPTION: REMOVE AND REPLACE(14)WINDOWS AND(])PATIO
(commencing with Section 7000)of Division 3 of the Business&Professions DOOR
Code and that my license is in fail force and effect.
I hereby affirm under penalp•of perjury one of the following two declarations:
I have and will maintain a certificate ofconsent to self-insure for Worker's
Compensation,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 provided lot by Sq. Ft Fit Or Arca: Valuation:$9390
Section 3700 of Labor Code,for the performance of die work for which this
permit is issued.
A I'N Number:34235054.00 Occupancy'lypr.
APPLICANT CF.RTI FICATION
I certify that 1 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 PERMIT EXPIRES IF WORK IS NOT STARTED
upon the above mentioned properly for inspection purposes. (We)agree to save
indemnily and keep harmless the City of Cupertino against liabilities,judgments, WITHIN 180 DAYS OF PERMIT ISSUANCE OR
costs,and expenses which may accrue against said City inconsequence of the 180 DAYS FROM LAST CALLED INSPECTION.
granting of this permit. Additionally,the applicant understands and will comply
with all non-point source regulations per npertino Municipal Code,Section y ✓� /LAjG� 1
9.18. Issued b /✓ Dale: /p
Signature ate
❑ OWNER-BUILDER DECLARATION RE-ROOFS:
All roofs shall be inspected prior to any roofing material being installed.If a roof is
beret,p affirm that I am exempt from the Contractor's License Law for one of installed without first obtaining an inspection,I agree to remove all new materials for
the following loo reasons: inspection.
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, Signature of Applicant: Date:
Business&Professions Code)
I,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,1usiness&Professions Code). ,\I,I,ROOF COVIiItINGS'fO BE CLASS"A"OR BF:1-I'Ek
1 hereby alina under penally of perjury one of the following three
declarations: II\%ARIIOUS AIATERIAIS DISCLOSURE
I have and will maintain a Certificate ofConsent to self insure for Worker's I have read the hazardous materials requirements under Chapter 6.95 of the
Compensation,as provided for by Section 3700 of the Labor Code,for the California I lealth&SafetyCode.Sections 25505,25533.and 25534. 1 n'ill maintain
perfdrnnance of the work for which this permit is issued. compliance with 11ne Cupertino i\Imnicipal Code,Chapter 9.12 and the Health&
I have and will maintain Worker's Compensation Insurance,as provided for by Safety Code,Section 25532(a)should I store or handle hazardous material.
Section 3700 of the labor Code,for the perfommnce of the work for which this 'Additionally,should I use equipment or devices which emit hazardous air
omit is issued. contaminants as defined by the Bay'y Area Air QualitManagement District I will
P maintain compliance with the Cupertino Municipal Code.Chapter 9.12 and the
I certify that in the perfommnce of One work for which this permit is issued,1 shall I lcahh&Safely Code,Secf ns 25505,25533,and 25534.
not employ any person in me),manner so as to become subject to the Worker's
Compensation laws of California. If,after making this certificate or exemption,I Owner or tori- Rent: Z
become subject to the Worker's Compensation provisions of the Labor Code,I must Dale: .
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
,\I'I'I.ICA\P CF,R'1'1PIC,\TION I hereby affirm that there is a construction lending agency for the performance of work's
I certify that I have read this application and state that the above information is for which this permit is issued(Sec.3097,Civ C.)
correct.1 agree to comply with all city and county ordinances and stale laws relating Lender's Name
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes.(We)agree to sae Lender's Address
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the
granting of this permit.Additionally,the applicant understands and will comply ,\RCI119'ECI"S DECLARATION
with all non-point source regulations per the Cupertino Municipal Code.Section I understand it),plans shall be used as public records.
9.18.
Licensed Professional
Signature Date
12-0 Wa) G
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
CUPERTINO (408) 777-3228 • FAX (408) 777-3333 • building(rJcupertino.org
❑ NEW CONSTRUCTION ❑ ADDITION r ALTERATION/TI ❑ REVISION/DEFERRED ORIGINAL PERMIT
PROTECT ADDRESS - APN 2
OWNERNAMEN I PHONE _ 17 , E-MAIL
)0i POIJO Sun, qJ
STREET ADDRESS CITY. STATE,ZIP FAX
1010C ra,��eo 4kk Or-CONTACT NAME SPHONE Q EMAIL
to
STREET ADDRESS 1 1CrrY,STATE ZIP ;U Qf, FAX
DOWNER 0 OWNERSUa.DER 0 OWNER AGENT u CONTRACTOR ❑CONTRACTORAGENT ❑ ARCHRECr ❑EYGLNEER ❑ DEVELOPER ❑ TEIANT
CONTRACTOR NAME LICENSE NUMBER LICENSE TYPEI BUS.LIC d
COMPANY NAME 0 E-MAIL I FAX
STREET ADDRESS CITY,STATE,ZI�, PHONE
NY G4 n o LA tof2,qr--0GrQ
6
ARCHITECTIENGINEER NAME LICENSE NUMBER I BUS.LIC x
COMPANY NAME E-MAIL I FAX
STREET ADDRESS CITY,STATE,ZIP I PHONE
DESCRIPTION OF WORK
6o Our c
EXIST 0 USE PROPOSED USE CON TYPE a STOR
USE TYPE OCC. I SQ.FT. I VALUATION(S)
EMS
TO NEW FLOOR DEMO TOTAL
AREA AREA ARF.\ NET ARE\
BATHROOM KITCHEN OTHEA
REMODELAREA REMODEL AREA REMODEL AREA
PORCH AREA DECK AREA TOTAL DECK/PORCH AREA GARAGEAREA: DETACH
❑ATTACH
N DWELLING UNITS% IS A SECOND UNIT LJYES SECON'DSrORY YES
BEING ADDED! 7NO ADDITION' NO
PILE-APPLICATION DYES T YES,PROVIDE COPY OF ISTHEBLDGAN YES oRECEIVED �g��4.,� OT TION:
Ic
PLANNINGAPPL-0 NO PLANNaI'G APPROVAL LETTER EICHLER[IONIC ,0 - `' 'fir 32- T,k� -may+_
T: T
n/ = D
By my signature below,1 certify to each of the follo I am the grope wner or authorized agent to act on the property owner's behalf. 1 have read this
application and the information I have provided' rrect. 1 have re escription of Work and verify it is accurate. 1 agree to comply with all applicable local
ordinances and state laws relating to buildin swction.411.a
a ri representatives of Cupertino to enter the above-ide "fie property for inspection purposes.
Signature of Applicanl/Agenr. Date: Z
SUPPLENIENTAL INFORMATION REQUIRED '� }- Y x-x^� - . "r•c-- .
Q :t4..PiaPLA,t,cHEcxneE_ '3 -r?" rtourncsLlP „'--:' t...g
New SFD or Multifamily dwellings: Apply for demolition permit for
"'' HE COUN
.�� OVER TTER? UILOINGPI:ANiREYTE\V
existing building(s). Demolition permit is required prior to issuance of building
permit for new building. y0 , 7S S,
_Commercial Bldgs: Provide acompleted Hazardous M0aterials Disclosure rsr:Nv fun �i �4 sLtcwoa
Form if any HazardMaterials aterials are being used as pan of this project -'
_Copy of Planning Approval Letter or Meeting with Planning prior toi#GE _i .si c .t 1❑— �-Dew _ , rye
submittal of Building Permit application. O \uao> A _ I � S^NR\AT]EWER DIST QCT
S�.SEb'VIROh\ENTAL HEA LTH�•_�
BldgApp_1011.doc revised 06/21/11 _
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