12110081 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 22264 CARTA BLANCA ST CONFRACFOR: YAKKUNDI NACI'IIKETA PERMITNO: 12110081
AND POONAM '
OWNER'S NAME: .YAKKUNDI NACHIKETA AND POONAM 21264 C\RTA BLANCA ST DATE ISSUED: 11/15/2012 '
OWNER'S PHONE: 4089106524 CUPERTINO,CA 95014 PI IONS NO:
❑ LICENSED CONI'RACI'OR'S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT r PLUMB r
License Class -Lie.H
_ RIECH r RESIDENTIAL r COMMERCIAL r
Contractor Date
hereby nliirm than am licensed under the provisions of Chapter 9 JOB DESCRIPTION:ADD(I])LED CAN LIGHTS TO LIVING AND FAMILY
(commencing with Section 1000)of Division 3 of the Business&Professions ROOM,
Code and that my license is in full force and effect. RELOCATE DRYER AND MOVE GAS LINE:AND VENT AND ADD
A CIRCUIT,RECESS THE WASHER BOX
hereby affirm under penaltyof perjury one of the following two declinations:
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 which this 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
permit is issued. ' Sq.Ft Floor Area: Valuation:53000
APPLIC\N"f CERTIFICATION'
I certify that I have read this application and state that the above information is APN Number:32613048.00 Occupancy Type:
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
indemnifY and keep harmless the Cily of Cupertino against liabilities,judgments. PERMIT EXPIRES IF WORD IS NOT STARTED
costs,and expenses which may accrue against said City in consequence of the
granting of this permit. Additionally,the applicant undesumds told will comply WITHIN 180 DAYS OF PERMIT ISSUANCE OR
with all non-point source regulations per the Cupertino Municipal Code.Section 180 DAYS FROM LAST CALLED INSPECTION.
9.18.
Signature Date Issued by: /��� R/G� Date: ��•�p
;OWNER-RUILDER DECLARATION
hereby affirm that I am exempt from the Contractor's License Law for one of RE-ROOFS:
the following bvo reasons: All roofs shall be inspected prior many roofing material being installed.]fit roof is
I,as owner of the properly,or my employees with wages as their sole compensation, installed without first obtaining an inspection.I agree to remove all new materials for
will do the work,and the structure is not intended or offered for sale(Sec.7044, inspection.
Business&Professions Code)
I,as owner of the properly,am exclusively contracting with licensed contractors to Signature of Applicant: Date:
construct the project(Sec.7044,Business&Professions Code).
leach}'affirm under penalty of perjury one of the follmring three
ALL ROOF COVERINGSTO BE CLASS"A"OR BETTER.
declarations:
I have and will maintain a Certificate of Consent to self-insure for Worker's HAZARDOUS NIATE.RIALS DISCLOSURE
Compensation,as provided for by Section 3700 of the Labor Code,for the
performance of the work for which this pernit is issued. I have read the hazardous materials requirements under Chapter 6.95 of the
I have and will maintain Worker's Compensation Insurance,as provided for by California Ilcalth&Safety Code,Sections 25505,25533,and 25534. 1 will maintain
compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
Section 3700 of the Labor Code,for the performance of the work for which this Safety Code,Section 25532(a)should I store or handle hazardous material.
permit is issued Additionally,should I use equipment or devices which emit hazardous air
I certify that in the performance of the work for which this permit is issued,1 shall contaminants as defined by the Bay Arca Air Quality Management District 1 will
not employ any person in any manner so as to become subject to the Worker's maintain compliance with the Cupertino Municipal Code,Chopter 9.12 and the
Compensation Imus of California. If,after making this certificate of exemption,I IlrnItlr �F S e v Code,Se tions 25505.25533,and 25534.
become subject to the Worker's Compensation provisions of the Labor Code,I must ^ Id,
forthwith comply with such provisions or this permit shall be deemedrevoked Ow a ],I rte ag L S"',n/u✓ Z01 v
Y Date:
APPLICANT CERTIFICATION CONSTRIVIJON LENDING AGENCY
I cenify that I have read this application and state that the above information is
correct.I agree to complywilh all city and county ordinances mad state laws relating 1 herchy affirm that there is a construction lending agency for the performance of work's
to building construction,and hereby authorize representatives of this city to enter for which this permit is issued(Sec.3097,Civ C.)
upon the above mentioned property for inspection purposes.(We)agree to save Lender's Name
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the Leader's Address
grunting of this p antra.Additionally,the npplicart understands and will comply
with all non-poi ounce regulnlims per the Cupertino Municipal Code,Swim ARCHITEC'I"S DECLARATION
NITON .
9.18.
�•�12 I understand my plans shall be used as public records.
Signature Dae
Licensed Professional
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE •CUPERTINO, CA 95014-3255 -
C U PERTINO (408) 777-3228• FAX (408)777-3333 • building8cupertino.oro
❑ NEW CONSTRUCTION ❑ ADDITION ALTERATIONITI ❑ REVISION/DEFERRED ORIGINAL PERMIT.
PROJECTADDRESS APNq
OWNERNAME PH �SY+ � E;AIAIL ,
STREET ADDRESSCITY, STATE,ZIP FAX
�t
r-7�rX--)- ,- 4 (-1ZT AL- it •7T 0 cA- ,.'Y)
CONTACT NAME PHONE E-MAIL
STREETADDRESS CITY,STATE, ZIP FAX
OWNER 13 OWER-BUILDER 0 OWNER AGENT 0 CONTRACTOR O CONTRACTOR AGENT 0 ARCHITECT 0 ENGINEER 0 DEVELOPER O TENANT
CONTRACTOR NAME �J �� LICETSENIJMBER LICEISETYPE BUS.LIC:
XCOMPANYNAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
ARCHITECTIENGINEER NAME LICENSE NUMBER BUS.LIC 9
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
DESCRIPTION OF WORT: _7 /J
r Ll r �b1 lU� �� =� _I tit=-- ,t•Z Y tZ— Ui�C _.
c.( "_U -rs CRT►2
EXISTING USE PROPOSED USE CONSTR. E C STORIES/_T) v USE TYPE OCC. SQ.FI'. VALUATION(S)
EATSTG NEW FLOOR DEMO TOTAL
AREA AREA AREA NET AREA
BATHROOM KrTCHEN OTHER
REI.IODEL AREA REMODEL AREA REMODEL AREA
PORCHAREA DECKAREA TOTALDECK ORCHAREA I GARAGE AREA: LJDETACH
❑ATTACH
0DWEUINGUNTTS: ISA SECOND UNIT ❑YES SECOSDSTORY ❑YES
DEINGADDED? ENO ADDITION? E]NO
PRE-APPLICATION ❑1'ES IF YES.PROVmE COPY OF IS THE BLDG AN ❑YES 'RECEIVED BY+, ' ,�{t' i TOTAL VALUATION:
PLANNIdGAPPL% ENO PLANNING APPROVAL LETTER EICHLERHO.ntE? ENO [y3":,I�'`
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 havf rovided is correct. I 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 I I i onstruction. VnIthorize representatives of Cupertino to enter the above-identified property for inspection purposes.
Signature of Applicant/AgenL' Date:
SUPPLEMENTAL RNIFORIMATION REQUIRED . `Y6'I' " ''ti^' - .�,�'e�, ` r
�yPLAR,CHECK;T,1',1'E'�' y' "�r�a�,.A��V�-;S:��ROUTINC;SGIP ?y$
New SFD or Multifamily dwellings: Apply for demolition permit for qmgmg, ,- aEti 5"`- Jt�`•v '
existing building(s). Demolition permit is required prior to issuance of buildino Zt 5 S`autt.mncLAN �E\v
permit for new building. >' ''I
P S �� ENrREss J O�N Nc PLAN-RE,
_Commercial Bldgs: Provide a completed Hazardous Materials Disclosure O sTA,NDeRD }5'ss�` O ruDLTe\coRls - ;
for n if any Hazardous Materials are being-used as part of this project. ` -rte' '�t'' '. •-''' - + ,: . r
'�❑R�1lAItCE \ :"'„y+'ti '�y4 1'A❑^ FIREDEPT - .�
_Copy of Planning Approval Letter or Meeting with Planning prior to `-x`rl
submittal of Building Permit application- 0R ,w�£SA�IyITARYSH\\EIi'DISTRICf
WEIE�N'\7R O4�NME1,N'-A-HE.At:TH=JAGa,
BldgApp_1011.doc revised 06/21/11
CITY OF CUPERTINO
FEE ESTIMATOR - BUILDING DIVISION
ADDRESS: 22264 Carta Blanca DATE: 11/15/2012 REVIEWED BY: Sean
APN: BP#: VALUATION: 1$3,000
*PERMIT TYPE: ' Building Permit PLAN CHECK TYPE: Alteration/ Repair
PRIMARY SFD or Duplex PENTAMATION 1REAP10
USE: PERMIT TYPE:
WORK Add 11 LED can lights to living and family room relocate dryer and move gas line and vent and add a
SCOPE circuit, recess the washer box.
Sheth. Plan Check Plumb. Plan Check 0.0 hrs $0.00 Elec. Plan Check 0.0' hrs $0.00
blech. Permit Fes: Plumb. Permit Fee: IPPERidIT Elec. Permit.Fee: /EPERMIT
Other Afech.Insp. L-1 I Other Plumb Insp. 0.0 hrs $45.00 Other Elec. Insp. 0.0 [its $45.00
Mcch.lnsp.Fee: Plumb. loy.Fre: like.Insp.Fee:
NOTE: This esrimate does not include jeer due to other Departments(i.e. Planning, Public II'orks, Fire,Sanitary Sewer District,School .
District,etc. . These feav are baser/on the prelintinan information available and are only an estimate. Contact rite Dept for arlrhs'!info.
FEE ITEMS (Fee Resolution 11-053 E2 7///121 FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 1 # Electrical
Suppl. PC Fee: 0 Reg. O OT F0-01hrs $0.00 $45.00 1BRE,1fRECFP Recep/Switch/Outlets
PME Plan Check: $0.00 11 1 Electrical
Permit Fee: $0.00 $67.00 IBRE,taFUT Fixtures, Lighting
Suppl. Insp. Fee:O Reg. 0 OT 0.0 hrs $0.001= # Plumbing
PME Unit Fee: $0.00 $67.00 IPGASRES Piping, Gas<=4 Outlets
PME Permit Fee: $90.00
Consoitclion Tax:
Administrative Fee: IAD,MIN $42.00 0
Work Without Permit? O Yes 0 No $0.00 0
Advanced Planriine Pee: $0.00 Select a Non-Residential 0
.Travel Documentation Fee: ITRA VDOC $45.00 Building or Structure 0
Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item
Blde Stds Commission Fee: IBCBSC $1.00
SUBTOTALS: $178.50 $179.00 TOTAL FEE: $357.50
Revised: 10/01/2012
OWNER-BUILDER DISCLOSURE FORM
COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION
10300 TORRE AVENUE •CUPERTINO, CA 95014-3255
CUPERTINO (408)777-3228 • FAX(408)777-3333•buildinaecuoertino.ora
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:
SITE ADDRESS Ck
2L ✓'MM � 5 f,WIC11:170V SDI APN )_6 _ I�— D IE- (fU BP#
OWNE4NAME 1 ' K �( p OWNER ADDIRESS _
DESCRIPTION OF WORK:j 1�- uMDDD-7L_ ,1fD 9GAW Uel $
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.)
ISI 1. 1 understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner-
ilder' building permit that erroneously implies that the property owner is providing his or her own labor and material
personally. I, 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
insp rance coverage for injuries to workers on my property.
2. 1 understand building permits are not required to be signed by property owners unless they are responsible for
construction 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 fled in his or her
name instead of my own.
t4. I understand Contractors are required by law to be licensed and bonded in California and to list their license
nmbers 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.
Ion
V' 1 6. 1 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.
t
7. 1 understand under California Contractors' Stale License Law, an Owner-Builder who builds single-family
ential 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
U-8.
rformed under contract with a licensed general building Contractor.
I 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.
OmnerBuilderrorm 3010.doc revised 04/14//0
leve
1 understand I may obtain more information regarding my obligations as an"employer"from the Internal
evenue Service, the United States Small Business Administration, the California Department of Benefit Payments,
and the California Division of Industrial Accidents. I also understand I may contact the California Contractors' State
License Board (CSLB)at 1-800-321-CSLB (2752)or www.cslb.ca.gov for more information about licensed
contractors.
V10. 1 am aware of and consent to an Owner-Builder building permit applied for in my name, and understand that I
a /the party legally and financially responsible for proposed construction activity at the site address listed above.
011. 1 agree that, as the party legally and financially responsible for this proposed construction activity, I will abide
6'yiall applicable 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 contractors are regulated by laws designed to protect the public. If
you contract with someone who does not have a license, the Contractors' State License Board may be unable to
assist you with any financial loss you may sustain as a result of a complaint. Your only remedy against unlicensed
Contractors may be in civil court. It is also important for you to understand that if an unlicensed Contractor or
employee of that individual or firm is injured while working on your property, you may be held liable for damages. If
you obtain a permit as Owner-Builder and wish to hire Contractors, you will be responsible for verifying whether or not
those Contractors are properly licensed 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 form 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 driver's license,
form notarization, or other verification acceptable to the city maybe required to be presented when the permit is issued
to verify the property owner's si natur I All
Property Owner's Signature: Date: tS n nr-20I L
(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 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 owner's
signature.
Property Owner's Signature: Date:
OwnerBuilderForm 20I0.doc revised 04//4/10