12110144CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 22403 RIVERSIDE DR I CON`OVEKIENT. BROTHERS HOME I PER\Irr NO: 12110144
OWNER'S NAME: KAKAR DEEPAK AND MENON LEENA 12511) DOUGLAS BIND I DATE ISSUED: 1128/2012
OWNER'S PIIONE: 4083)61993 I ROSIIVILLE. CA 95661 I PI IONE NO: (408)296.0680
❑ LICENSED CO,NfRACI'OR'S DECLARATION
License Class - Lie. 0 V1 1009
Contractor VD w, L LYtp DaieI7�J/
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.
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 p'orker'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 die work for which this
permit is issued.
APPLICANT CERTI FIC\'I'ICIN
I cenify 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
upon the above mentioned property for inspection purposes. (We) agree to save
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
with all non -pot ource regulations per the Cupertino Municipal Code, Section
9.18.
Signature Date
❑ tON ILI)ERI)ECLARA'1'ION
hereby affirm that I.am exempt from the Contractor's License Law for one of
the following mo reasons:
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)
1, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec.7044, Business R Professions Code).
I hereby affirm under penalty of perjury one of the following three
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
perfomiance of the work for which this permit is issued.
I have and will maintain porker'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.
I cenify that in the perfommnce of the work I'or which this permil is issued, I shall
not employ any person In my manner so as to become subject t.0 the Worker's
Compensation laws of California. If, after making this certificate of exemption, I
become subject to the Worker's Compensation provisions of the Labor Code, I must
forthwith comply with such provisions or this permit shall be deemed revoked.
AI'I'LICANI' CF.R'1'11'IC.VI'ION
I certify that I have read this application mid state that the above information is
correct. I agree to comply with all cit' and county ordinances and state laws relating
to building construction, mid 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 Cityof 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
with all non -point source regulations per the Cupertino Municipal Code, Section
9.18.
Signature Date
BUILDING PERMIT INFO: BLDG r ELECT C PLUMB r
D1ECH r RESIDENTIAL - 7 COMMERCIAL —
,1013 DESCRIPTION: I 1 WINDOWS AND 2 DOORS
Sq. FI Floor Arca. I Valuation: $9430
APN Number: 35603036.00 1 Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
Issued Ualerr�/ �Z F-
RE-ROOFS:
?
RF;ROOF'S:
All roofs shall be inspected prior to any roofing material being installed. If a roof is
installed withota fust obtaining an inspection, I agree to remove all new materials for
inspection.
Signature of
Dale:
ALI, ROOF COVERINGS TO RE CLASS "A" OR BEI"ITR
IIA%ARDOUS d1ATERL\LS DISCLOSURE
have read the hazardous materials requirements under Chapter 6.95 of the
California Ilealth & Safety Code. Sections 25505, 25533, and 25534. I Brill maintain
compliance with the Cupertino Municipal Code. Cha pier 9.12 and the Ilealth &
Safety Code. Section 25532(a) should I store or handle hazardous material.
Additionally, should 1 use equipment or devices which emit hazardous air
contaminants us defined by the Bay Area Air Quality Management District I will
maintain compliance with the Cupertino Municipal Code. Chapter 9.12 and the
Ilndmh & Safety Code. Sections 25505, 25533, and 25534.
agent: Dale: /�-151
CONSTRUCIJON LENDING AGENCY
I hereby affirm thin there is a construction lending agency for the performance of work's
for which this permit is issued (Sec. 3097, Civ C.)
Lender's N'anmc
Lender's
ARCIIITEM'S DECLARATION
I understand my plans shall be used as public records.
Licensed Professional
CUPERTINO
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT - BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228 • FAX(408) • buildinG akuoertino.orD
❑ NEW CONSTRUCTION ❑ ADDITION - ALTERATION/TI ❑ REVISION/DFFFRRF.D ORTMNAI. PFRMITe
PROD EC r ADDRESS 2 s n6
APNtl Y ) 02
-
OWNERNAME Uk1J
E-MAIL
PHONE (, A3 I
STREET ADDRESS
CITY, STATE, ZIP C /iA SD`
I FAX
CONTACT NAME
PHONE /rJ E-MAIL
(, J
STREET ADDRESS �/�ya ✓
CITY, STATE, ZIP
FAX
❑ OWNER -BUILDER ❑ OY WER AGENTC`L-r ONZICTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME
LICENSE NUMBER &JI O
LICENSETYPEb C/
BUS. LICE
COMPANYNAME
E-MAIL
FAX
STREET ADDRESS '�,�^ =
CITY, STATE, ZIP"
(pH N'E
`
ARCHITECTIENGINEER NAME
LICENSE NUMBER
BUS. LIC N
COMPANY NAME
E-MAIL
FAX
STREET ADDRESS
CITY, STATE, ZIP
PHONE
DESCRIPTION OF WORK
I
'`
EXISTING USE
PROPOSED USE
CONSTIL TYPE
bSTORIES
USE
TYPE
OCC.
SQ.FT.
VALUATION (S)
EXISTG
AREA
ARE FLOOR
AREA
DEMO
AREA
TOTAL�o
NET AREA
(F('
BATHROOM
KITCHEN OTHER
RENIODELAREA
R-NODELAREA REAfODEL AREA
PORCHARFA DECKAREA TOTALDECK/PORCH AREA GARAGEAREA: DETACH
D ATTACH
I
NDWELLNGUNT6:
IS A SECOND UN IT ❑YES
SECOND STORY ❑YES
OCTSGADDED? [3 NO
ADDITION? DNO
PRE -APPLICATION DYES T YES, PROYTDE COPY OF
PLANT'INGAPPLZ NO PLANNING APPROVAL LETTER
IS THE BLDG AN ❑YES
EICHLERHO,NE? NO
REG_EIVEDBY'. ., j- "-°
KY
TOTAL VALUATION:
�ti
By my signature below, I certify to each of the(olloYY•ing:properry owner or authorized agent to act on the property owner's behalf. 1 have read this
application and the information Ihave provided is Lorre ve mad the Descrier ClA'ork and verify it is accurate. I agree to comply with all applicable local
ordinances and state law'srelatine to building cons n. 1 authorize mprese res of Cupertino to enter the above-idennfi 'property for inspection purposes.
Signature of Applicant/AgenC Dace: f% ZY ,%
SUPPLEMENTAL INTFORKikTION REQUIRED
5PT�`!.S*a '-Cft �
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,
.,ROUTI\QSCIP
. New SFD or Multifamily dwellings: Apply for demolition permit for
existine buildings) Demolition is to issuance building°Yr�•
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permit required prior of
permit for new building.
L �
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O P�G� VIEW
Commercial Bldgs: Provide a completed Hazardous Materials Disclosure
*�O'W' YR s::r. s Y
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form If any Hazardous Materials are being used as part of this project
Copy of Planning¢ Approval Letter or Meeting With Planning prior to
p0 �I.ARCE �� �! •`� 'r-
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❑ UA'JOR
D SANITARY Ew ER DISTRICT
submittal of Building Permit application.
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WE- ENl`IR O\NfENTAL HEALTH-
31dgApp_201 Ldoc revised 06/21/11
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CUPERTINO
CONTRACTOR / SUBCONTRACTOR LIST
Building Department
City Of Cupertino
10300 Torre Avenue
Cupertino, CA 95014-3255
Telephone: -40&777,3228
Fax: 40&777-3333
JOB ADDRESS: V 0
3 k ve^
PERMIT #
OWNER'S NAME: 0r�e
Z• V40 ko
PHONE # '-,-S
GENERAL CONTRACTOR:
BUSINESS LICENSE # " %f
ADDRESS:
vL Avr
CITY/ZIPCODE: Su.A - (,
*Our municipal code requires all businesses working in the city to have a 'ty of Cupertino business license.
NO BUILDING FINAL OR FINAL OCCUPANCY INSPECT i'(S) N'ILL BE SC14EDULED UNTIL THE
GENERAL CONTRACTOR AND ALL SUBCONTRi AVE OBTAINED A CITY OF CUPERTINO
BUSINESS LICENSE.
1 am not using any subcontractors:
Signature Date' '
Please check applicable subcontractors and complete the following information:
t/
SUBCONTRACTOR
BUSINESS NAME
BUSINESS LICENSE #
Cabinets & Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring / Carpeting
Linoleum / Wood
Glass / Glazing
Heating
Insulation -
Landscaping
Latfiing
Masonry
Painting / Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
/ AV17,�-
f Date
CITY OF CUPERTINO
F" FEE ESTIMATOR — BUILDING DIVISION
jk
ADDRESS: 22403 riverside dr.
DATE:
RE\'IE\VED B\': bobs.
Mock Permit Fee:
APN:
BP#:
'VALUATION:
$9,430
*PERMIT TYPE: Building Permit
PLAN CIIECK TYPE: Alteration / Repair
PRIMARY SFD or Duplex
USE:
Elco. insp. res-,
PFRMINATION 1GENRES
PERMIT T\'PE:
WORK
11 windows and 2 doors. 71
SCOPE
$0.00
NOTE: This ectinmte does not include feev clue to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School
District, etc.). There feev are based on the Prelintinan, information arnilable and are onh, an estimate. Contact lite Dept for whin? info.
FEE ITEMS (Fee Resolution 11-053 EB: 7/1/12)
Alech. Plan Check
Plumb. Plan Check
Elec. Ilan Check
Mock Permit Fee:
Plumh. Permit rec:
rias. Permit Fra:
Other klech. Insp.
Other Plumb Insp.
Other Floe. Insp. Li I
,Mesh. Insp. rec:
Plumb. h,.,p. Fee:
Elco. insp. res-,
NOTE: This ectinmte does not include feev clue to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School
District, etc.). There feev are based on the Prelintinan, information arnilable and are onh, an estimate. Contact lite Dept for whin? info.
FEE ITEMS (Fee Resolution 11-053 EB: 7/1/12)
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee:
$0.00
= #
$533.00
Window / Sliding Glass Door
1lf'1NREP Replacement
Suppl. PC Fee: 0 Reg. 0 OT
FO.0
hrs
$0.00
PME Plan Check:
$0.00
Permit Fee:
$0.00
Suppl. Insp. Fee.0 Reg. 0 OT
0.0
1 hrs
$0.00
PME Unit Fee:
$0.00
PME Permit Fee:
$0.00
Consnvction Tax:
Administrative Fee:
0
(D
Work Without Permit? 0 Yes (F) No
$0.00
Advanced Planning Fee:
$0.00
Select a NonResidential0
Building or Structure
0
i
Travel Documentation Fees:
Strong Motion Fee: IBSEIS,t11CR
$0.94
Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC
$1.00
SUBTOTALS:
$1.94
$533.00
TOTAL FEE:
1 $534.94
Revised: 10/01/2012