12120104 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 21.723 CASTLETON ST CONTRACTOR:COOPER BROTHERS,INC. PERMIT NO: 12120104
OWNER'S NAME: RAMAKRISHNA JOSHI AND NAGARAJA JYOT 6017 SNELL AVE STE 331 DATE ISSUED: 12/19/2012
OWNER'S PHONE: 4084904923 SAN JOSE,CA 95123 PHONE NO:(408)437-2442
❑ LICENSED CONTRACTOR'S DECLARATION r— I—
S BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class c 2-0Lic.#
MECH r RESIDENTIAL F COMMERCIAL r
Contractor /tom l� * S Date Z / 1 Z
I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:INSTALL NEW MINI SPLIT SYSTEM
(commencing with Section 7000)of Division 3 of the Business&Professions
Code and that my license is in full force and effect.
I 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 which this permit is issued. Sq.Ft Floor Area: Valuation:$15423
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
permit is issued. APN Number:35618069.00 Occupancy Type:
APPLICANT CERTIFICATION
I certify 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 state laws relating PERMIT EXPIRES IF WORK IS NOT STARTED
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save WITHIN 180 DAYS OF PERMIT ISSUANCE OR
indemnify and keep harmless the City of Cupertino against liabilities,judgments, 180 DAYS FROM LAST CALLED INSPECTION.
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 ]sued Date�Zc/ 'l
9.18.
Signature Z Date 2--11
RE-ROOFS:
❑ OWNER-BUILDER DECLARATION All roofs shall be inspected prior to any roofing material being installed.If a roof is
installed without first obtaining an inspection,I agree to remove all new materials for
I hereby affirm that I am exempt from the Contractor's License Law for one of inspection.
the following two reasons:
1,as owner of the property,or my employees with wages as their sole compensation, Signature of Applicant: Date:
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 exclusively contracting with licensed contractors to ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
construct the project(Sec.7044,Business&Professions Code).
I hereby affirm under penalty of perjury one of the following three HAZARDOUS MATERIALS DISCLOSURE
declarations: I have read the hazardous materials requirements under Chapter 6.95 of the
1 have and will maintain a Certificate of Consent to self-insure for Worker's California Health&Safety Code,Sections 25505,25533,and 25534. 1 will maintain
Compensation,as provided for by Section 3700 of the Labor Code,for the compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
performance of the work for which this permit is issued. Safety Code,Section 25532(a)should I store or handle hazardous material.
I have and will maintain Worker's Compensation Insurance,as provided for by Additionally,should I use equipment or devices which emit hazardous air
Section 3700 of the Labor Code,for the performance of the work for which this contaminants as defined by the Bay Area Air Quality Management District I will
permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
I certify that in the performance of theworkfor which this permit is issued,I shall Health&Safety Code,Sections 25505,25533,and 25534.
not employ any person in any manner so as to become subject to the Worker'sOw) au rize e"it
Compensation laws of California. If,after making this certificate of exemption,l (i Date: !A l /Z_
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. CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of"ork's
APPLICANT CERTIFICATION for which this permit is issued(Sec.3097,Civ C.)
I certify that I have read this application and state 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,
costs,and expenses which may accrue against said City in consequence of the ARCHITECT'S DECLARATION
granting of this permit.Additionally,the applicant understands and will comply I understand my plans shall be used as public records.
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18. Licensed Professional
Signature Date
GENERAL PERMIT APPLICATION MEP
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255
(408)777-3228• FAX(408)777-3333•building 5cuoertino.org misc
CUPERTINO
[]PLUMBING lq; CmkMCAL ❑ELECTRICAL ❑MISCELLANEOUS
PROJECT ADDRESS 77 C) AJ'N
IIERNAME A a>M Q �G r t S N ►�q P VQ Lig 0 -Ll q 23 1
E-1/,AIL
STREET ADDRESS S CITY, STATE,ZIP FAX G.vV` L
—7CONTACT NAME PHONE E-MAIL
STREET ADDRESS CITY,STATE, ZIP FAX
❑ OWNER ❑ OWNER-BUIIDER ❑ OWNER AGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME ,(�// / /�G 0 LICEN NU] ^ LI
CENSE O E BUSLIC -7
COMPANY NAME /1 O e r �6v-,-rA e✓` ►�d�/hE-MAIL FAX
STREET ADDRESS �� C11 �ca / PL' 3-) oY` -2 c,aE� —
ARCTiITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC x
COMPANY NAME' E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF FD or DUPLEX ❑ MULTI-FAMILY PROJECT IN WII DLAND ❑ YES PROJECT IN ❑YES IS THE BLDG AN ❑ YES
BUILDING: ❑COMMERCIAL URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑NO EICHLER HOME? ❑NO
DESCRIPTION OF WORK
1/VSla, x/ 141
r TOTAL VALUATION: / 41Z3 RECEIVED BY:
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 have provided's 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 b ' 'n stru n. I auth n pr entatives of Cupertino to enter the above-identified prop ;-y for inspection puPposes.
Signature of Applicant/Agent: Date: �r'I
71
PLEMENTAL INFORMATI REQUIRED OFFICE USE
ONLY
OVER-THE-COUNTER
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❑ EXPRESS
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❑ STANDARD
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❑ LARGE
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❑ MAJOR
MEPMIsc Opp 2011.doc revised 06121111
CITY OF CUPERTINO
FEE ESTIMATOR— BUILDING DIVISION
ADDRESS: 21723 castledon st. DATE: 12/19/2012 REVIEWED BY: bobs.
APN: BP#: *VALUATION: 1$15,423
*PERMIT TYPE: Mechanical Permit PLAN CHECK TYPE: Alteration /Addition / Repair
PRIMARY SFD or Duplex PENTAMATION FURN/AC
USE: PERMIT TYPE:
WORK iinstall new minis lits stem
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Heat Pump (<=1 OK cfm) 1 BREMAiR 1 # $67
TOTALS: 1 1 $67.00
Mech.Plan Check0.0 hrs $0.00
Mech.Permit Fee: IMPERMIT
Other Mech.Insp. 0.0 hrs
NOTE.This estimate does not include fees due to other Departments(i.e.Planning,Public Works,Fire,Sanitary Sewer District,School
District,etc.). Thesefees are based on the prelimina information available and are only an estimate. Contact the De t or addn'l info.
FEE ITEMS(Fee Resolution 11-053 Lff 7/1112) FEE QTY/FEE MISC ITEMS
Pian Chel—k.f, d
PME Plan Check: $0.00
PME Unit.Fee: $67.00
(PME Permit Fee: $45.00
Administrative Fee: (ADMIN $42.00
Work Without Permit? 0 Yes (F) No $0.00
r:f">'S:
Travel Documentation Feer ITRA VDOC $45.00
Strong Motion Fee: IBSEISMICR $1.54 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $1.00
SUBTOTALS: $201.54 $0.00J TOTAL FEE: $201.54
Revised: 10/01/2012
Building Department
City Of Cupertino
10300 Torre Avenue
Cupertino, CA 95014-3255
Telephone: 408-777-3228
C U P E RTI N O Fax: 408-777-3333
CONTRACTOR/ SUBCONTRACTOR LIST
JOB ADDRESS: 2-/7 2-3f/= o+� Sf PERMIT# I L-- -2- v� U
OWNER'S NAME: PHONE# doff �jo - ��}Lj
GENERAL CONTRACTOR: BUSINESS LICENSE# ;2 G 7 3
ADDRESS: o 1 -7s,L�( I <cc
v , ' CITY/ZIPCODE: 5a-., 57c,5e- �ot �l5^!23
*Our municipal code requires all businesses working in the city to have a City of Cupertino business license.
NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE
GENERAL CONTRACTOR AND ALL SUBCONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO
BUSINESS LICENSE. � �t�
I am not using any subcontractors: 4 - 2-11`"� Z
11
Signature Date
Please check applicable subcontrac ors and complete the following information:
SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets & Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring/ Carpeting
Linoleum/Wood
Glass/ Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Painting/Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
2-11 -T A Z
Owner/ContActor Signature D to