12120069CITY OF CUPERTINO BUILDING PERMIT I
BUILDING ADDRESS: 20272 NORTHCOVE SQ
OWNER'S NAME: MURUGAN RAVISHANKAR
OWNER'S PHONE: 4087208127
❑ LICENSED CONTRACTOR'S DECLARATION
License Class Lic. #
Contractor 1w. (C", % —Date—LL ` L
i - l 2
I 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.
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.
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.
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
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 -point source regulations per the Cupertino Municipal Code, Section
9.18.
Signature AX, 4,—Date
❑ OWNER- BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons:
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)
1, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec.7044, Business & 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
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.
I certify that in the performance of the work for which this permit is issued, I shall
not employ any person in any manner so as to become subject to 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.
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
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 -point source regulations per the Cupertino Municipal Code, Section
9.18.
Signature Date
CONTRACTO I PERMIT NO: 12120069
DATE ISSUED: 12/14/2012
PHONE NO:
BUILDING PERMIT INFO: BLDG f— ELECT I— PLUMB r-
MECH f— RESIDENTIAL F COMMERCIAL f—
JOB DESCRIPTION: ADD NEW GAS LINE FOR NEW STOVE TOP
Sq. Ft Floor Area: I Valuation: $800
APN Number: 31641075.00 1 Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM L CALLED INSPECTION.
Issued by: —Date:
RE- ROOFS:
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
inspection.
Signature of Applicant: Date:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
HAZARDOUS MATERIALS DISCLOSURE
I have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain
compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health &
Safety Code, Section 25532(a) should I store or handle hazardous material.
Additionally, should I use equipment or devices which emit hazardous air
contaminants as defined by the Bay Area Air Quality Management District I will
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
Health & Safety Code, Sections 25505, 25533, and 25534.
Own or uthorized ent:
Date:
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of work's
for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
Lender's Address
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Licensed Professional
M
IVA
V
CUPERTINO
GENERAL PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014 -3255
(408) 777 -3228 • FAX (408) 777 -3333 • buildino ..cuoertino.org
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CONTACT NAME 1 /
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❑ OWNER ❑ OWNER -BU=ER ❑ OWNER AGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT. ❑ ARcJ- -=--cT ❑ ENc;w=- ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME I LICENSE NUMBER(l7 % /' I (� C ("
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LICENSE TYPE
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USE OF SFD or DUPLEX ❑ MULTI -FAMMY
BLULDING: ❑ COMMERCLAL
PROJECT IN WILDLAND ❑ YFS PROJECT IN ❑ YES
URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑ NO
IS THE BLDG AN ❑ YS
00—=HOME? ❑ NO
DESCRIPTION OF WORK
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TOTAL VALUATION: �(� U 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 is correct. I have read the Description of Work and verify it is accurate. I agree to comply vrith all applicable local
ordinances and state laws relating to b ' dir construction. I a otize representatives of Cupertino to enter the above- identifiedprope,.y for inspection pu;!�oses.
Sig —r ature of ApplicandAgeat: Date: �-
ST-TPLEMENTAL INFORMATION REQ=D
OF E USE ONLY
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OVER- THE - COUNTER
❑ EXPRESS
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❑ STANDARD
❑ LA.RGE
❑ MAJOR
Ai P.74sc,4pp_2011.doc revised 06121111
CITY OF CUPERTINO
Im FEE ESTIMATOR— BUILDING DIVISION
imlADDRESS:
20272 northcove square
DATE: 12/13/2012
REVIEWED BY: bobs.
UNITS
APN:
BP #:
`VALUATION: $800
*PERMIT TYPE: Plumbing Permit
PLAN CHECK TYPE: Alteration / Addition / Repair
PRIMARY SFD or Duplex
USE:
I
PENTAMATION 1 RPGAS
I PERMIT TYPE:
WORK
add new gas line for new stove top.
SCOPE
r1 uppl. III";/) Fee'
APPLIANCE / EQUIP TYPE
FEE ID
Plumb. Plan Check 0.0 hrs $0.00
QTY
UNITS
BP FEES
Fill, c. Permit /"Ce:
Piping, Gas < =4 Outlets
1 PGASRES
of Wr later. lnz p. Lj I
1
#
$67
flerinil Fc,i.
r1 uppl. III";/) Fee'
F71
PME Unit Fee:
$67.00
PME Permit Fee:
$45.00
6,onstruc tIton Kix:
Administrative Fee: IADMIN
$42.00
Work Without Permit? 0 Yes (j) No
$0.00
TOTALS:
Travel Documentation Fee: ITRAVDOC
$67.00
Strop Motion Fee: IBSEISMICR
NOTE: This estimate does not include fees due to other Departments (Le. Planning, Public Works, Fire, Sanitary Sewer District, School
n;ctri ,-r etr ►_ Thoco foot aro ha.cod on the nroliminary information available and are only an estimate. Contact the Dept for addh 7 info.
FEE ITEMS (Fee Resolution 11 -053 a.' 7/1112)
,11c, t,. lion
Plumb. Plan Check 0.0 hrs $0.00
F7c��_ Nov t:`hCz�J� — I f —
Permil FFc,"
Plumb. Permit Fee: IPPERMIT
Fill, c. Permit /"Ce:
Suppl. P(. Fee
Other Plumb Insp. 0.0 hrs $45.00
of Wr later. lnz p. Lj I
Ah clz. Irz�p (�'e:
11/11mlz hop /1-C":
1,17c,r. Ihsp, Fce:
NOTE: This estimate does not include fees due to other Departments (Le. Planning, Public Works, Fire, Sanitary Sewer District, School
n;ctri ,-r etr ►_ Thoco foot aro ha.cod on the nroliminary information available and are only an estimate. Contact the Dept for addh 7 info.
FEE ITEMS (Fee Resolution 11 -053 a.' 7/1112)
FEE
QTY/FEE
MISC ITEMS
Plan Check F<c
F
Suppl. P(. Fee
F
PME Plan Check:
$0.00
flerinil Fc,i.
r1 uppl. III";/) Fee'
F71
PME Unit Fee:
$67.00
PME Permit Fee:
$45.00
6,onstruc tIton Kix:
Administrative Fee: IADMIN
$42.00
Work Without Permit? 0 Yes (j) No
$0.00
,I(A'uncecl Plzrnrring fees:
Travel Documentation Fee: ITRAVDOC
$45.00
Strop Motion Fee: IBSEISMICR
$0.50
Select an Administrative Item
Bldp, Stds Commission Fee: IBCBSC
$1.00
SUBTOTALS:
$200.50
$0.001 TOTAL FEE
$200.50
Revised: 10/01/2012