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12120071CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 11141 CHADWICK PL CONTRACTOR: REPIPE 1 PERMIT NO: 12120071 OWNER'S NAME: UPPULURI VENKATA N AND KASHIBATLA R 14724 VENTURA BLVD STE 507 DATE ISSUED: 12/13/2012 OWNER'S PHONE: 4087188325 SHERMAN OAKS, CA 91403 PHONE NO: (818) 981 -5015 LICENSED CONTRACTOR'S DECCLLCARATION License Class Lic. #��75 (� Contractor / - S�Lyi' o Date 12'13'2 C %Z . 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.E Signature�_� C�e +- Date �^ Z f� Z ❑ OWNER- BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for one of the following two 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 & 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 BUILDING PERMIT INFO: BLDG r ELECT r PLUMB I- MECH f— RESIDENTIAL F_ COMMERCIAL f— JOB DESCRIPTION: COPPER RE -PIPE Sq. Ft Floor Area: I Valuation: $7750 APN Number: 35617079.00 1 Occupancy Type: PERMIT E P RES IF WORK IS NOT STARTED WITHIN AYS OF PERMIT ISSUANCE OR 180 DAY OM LAST CALLED INSPECTION. Issued by: Al l v + )3f ) 2 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. Owner or aut a agent: ��.� P r� Da �>�Z 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 u x CUPERTINO GENERAL PERMIT APPLICATION MEP COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014 -3255 misc 5 (408) 777 -3228 • FAX (408) 777 -3333 • buildino ,CUDertino.orq F7 PT T TU-P TMr, I ITvTrT.TAmrAT. I IFT.R(- TRTC'AT. 1 IMTSC'FT.LATTFnTIR FOWN ECTADDRESS dw L J PHONE E-MAIL STRE'Ef ADDRESS CITY, STATE, ZIP I FAX CANTACT NAME PHONE E -MAIL STREETADDRESS CITY, STATE, ZIP FAX ❑ OWNER ❑ OWNER- BUIIDER ❑ OWNER AGm,,T CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCi�TECT ❑ ENGiTTEER ❑ DEVELOPER ❑ TirNANT CONTRACTOR NAME 'G ! G LICENSE NUMBER LICENSE TYPE 7� BUS. LIC 4 COMPANY NAME C E -MAIL FAX STREET ADDRESS r '% / Vo,� �/ CITY, STATE, ZIP ui �r C PHONE (� f� , O 1� ARCHITECl/ENGINEER NAME LICENSE NUMBER BUS. LIC # COMPANY NAME' E -MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE USE OF j2kFD or DUPLEX BUTLDING: ❑ COMMERCIAL ❑ MULTI - FAMILY PROJECT IN WI DLAND ❑ YES I PROJECT IN ❑ YES URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑ NO IS THE BLDG AN ❑ YES EICHLER HOME? ❑ NO DESCRIPTION OF WORK e b ov t TOTAL VALUATION: U T 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 Arith all applicable local ordinances and state laws relating to building co stru�tion. I au R resentatives of Cupertino to enter the above- identi iedprope. ;y for inspection purposes. Signature of Applicant/Agent: e: .el � Date: �� 3 ° Zt % Z SUPPTZIMETtAL INFORMATION REQUIRED OFFICE USE ONLY E' U U OVER- THE - COUNTER ❑ EXPRESS ❑ STANDARD ❑ LARGE ❑ MAJOR MEP. ua4pp_2011.doc revised 06121111 CITY OF CUPERTINO FEE ESTIMATOR — BUILDING DIVISION APPLIANCE / EQUIP TYPE ADDRESS: 11141 Chadwick PI. DATE: 12/13/2012 REVIEWED BY: gs UNITS APN: BP #: *VALUATION: 1$7,750 *PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration / Addition / Repair PRIMARY SFD or Duplex USE: $13 PENTAMATION 1 RPRP PERMIT TYPE: WORK Copper re-pipe SCOPE APPLIANCE / EQUIP TYPE FEE ID Plumb. Plan Check 0.0 hrs $0.00 QTY UNITS BP FEES Fkc. Pcollir Re -Pipe Interior 1PRREPIPE Othci° 1,170 . Inst). 1 # $13 Permit Fee: Supp/. Irrsp F PME Unit Fee: $13.00 PME Permit Fee: $45.00 C,U31J7tYlC'ttOYt 1CLV. Administrative Fee: IADMIN $42.00 Work Without Permit? 0 Yes (F) No $0.00 TOTALS: Travel Documentation Fee: ITRAVDOC $13.00 Strong- Motion Fee: IBSEISMICR NOTE: This estimate does not include fees due to other Departments (Le. Planning, Public Works, Fire, Sanitary Sewer District, School District. etc ). These fees are based on the nreliminary information available and are only an estimate Contact the Dept for addn 7 info. FEE ITEMS (Fee Resolution 11 -053 Eff' 711112) ltech. Plan C `hcc.b Plumb. Plan Check 0.0 hrs $0.00 17c�!. t'1�ol t;h"Ck I'A'cll. 11"oWt F""': Plumb. Permit Fee: IPPERMIT Fkc. Pcollir hli�P Other Plumb Insp. 0.0 hrs $45.00 Othci° 1,170 . Inst). 1'cc: PME Plan Check: Fcc: NOTE: This estimate does not include fees due to other Departments (Le. Planning, Public Works, Fire, Sanitary Sewer District, School District. etc ). These fees are based on the nreliminary information available and are only an estimate Contact the Dept for addn 7 info. FEE ITEMS (Fee Resolution 11 -053 Eff' 711112) FEE QTY/FEE MISC ITEMS Plan Check Tee: :Sapp/. PC Fee PME Plan Check: $0.00 Permit Fee: Supp/. Irrsp F PME Unit Fee: $13.00 PME Permit Fee: $45.00 C,U31J7tYlC'ttOYt 1CLV. Administrative Fee: IADMIN $42.00 Work Without Permit? 0 Yes (F) No $0.00 '1dtionced Plarming Fees: Travel Documentation Fee: ITRAVDOC $45.00 Strong- Motion Fee: IBSEISMICR $0.78 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $1.00 SUBTOTALS: $146.78 $0.00 TOTAL FEE: $146.78 Revised: 10/01/2012