13020111 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10555 ORANGE TREE IN CONTRACTOR:MORE LAND PERMIT NO:13020111
CONSTRUCTION
OWNER'S NAME: KRISHNAMURTHI AMUDHAN AND MANICKAM 1454 RUSTED AVE DATE ISSUED:02/20/2013
OWNER'S PHONE: 4088739970 SAN JOSE,CA 95125 PHONE NO:(408)221-0892
❑ - LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL U COMMERCIAL
License Class tic.# SIA \V A \ TEMPORARY POWER POLE
o tiContract or Date_
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. Sq.Ft Floor Area: _ Valuation:$500
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 APN Number:31634010.00 Occupancy
TYPe:
permit is issued.
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED
correct.I agree to comply with all city and county ordinances and state laws relating WITHIN 180 DAYS OF PERMIT ISSUANCE OR
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save 180 DAYS FROM-UST CALLED INSPECTION.
indemnify and keep hamrless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the Z O
Issu Date:
granting of this permit. Additionally,the applicant understands and will comply
with all non-point source regulations_ err r Cupertino Municipal Code,Section
9.18.
RE-ROOFS:
Signature V Date �\\ 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.
❑ - OWNER-BUILDER DECLARATION
Signature of Applicant: Date:
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
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 HAZARDOUS MATERIALS DISCLOSURE
construct the project(Sec.7044,Business&Professions Code.). I have read the hazardous materials requirements under Chapter 6.95 of the
California Health&Safety Code,Sections 25505,25533,and 25534. 1 will -
I hereby affirm;under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
declarations: - Health&Safety Code,Section 25532(a)should I store or handle hazardous
I have and will maintain a Certificate.of Consent to self-insure for Worker's material. Additionally,should I use equipment or devices whichemithazardous
Compensation,as provided for by Section 3700 of the Labor Code,for the air contaminants as defined by the Bay Area Air Quality Management District I
. performance of the work for which this permit is issued. will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and.
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sections 255 3 rid 25534.
Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agent: Date:
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 anymanner so as to becomesubject to the Worker's
Compensation laws of California. K after making this certificate of exemption,I CONSTRUCTION LENDING AGENCY
become subject to the Worker's Compensation provisions of the Labor Code,I must I hereby affirm that there is a construction lending agency for the performance of
forthwith comply with such provisions or this permit shall be deemed revoked. work's for which this permit is issued(Sec.3097,Civ C.) .'
Lender's Name
APPLICANT CERTIFICATION Lender's Address
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 concoction;and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes.(We)agree to save ARCHITECT'S DECLARATION
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records.
granting of this permit.Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section Licensed Professional
9.18.
Signature - - Date
CITY OF CUPERTINO
FEE ESTIMATOR-BUILDING DIVISION
ADDRESS: 10555 ORANGE TREE LN DATE: 02120/2013 REVIEWED BY: MELISSA
APN: 316 34 010 BPl#: *VALUATION: $500
*PERMIT TYPE: Electrical Permit PLAN CHECK TYPE: Alteration/Addition / Repair
PRIMARY SFD or Duplex PENTAMATION 1REAP14
USE: PERMIT TYPE:
WORK TEMPORARY POWER POLE
SCOPE
APPLIANCE/EQUIP TYPE FEE ED QTY UNITS BP FEES
Temporary Power 1ERT<200 100 Amps $45
TOTALS: .?i $45.00
Meeh. Plan Check Plumb. Plan Check Elec.Plan Check 0.0 1 hrs $0.00
Me& Permit Fee: Plumb. Permit Fee. Elec.Permit Fee: 1EPERMIT
Other Meeh.Insp. Other Plumb Insp, Other Elea Insp. Ehrs $45.00
,b/ech. InsP. Pee: Plumb. hup. Fee: Elec,Insp.Fae:
NOTE:This estimate does not includejees due to other Departments(le.Planning,Public Works,Fire,Sanitary Sewer District,School
District etc. . These ftes are based on therelimina in ormadon available and are only an estimate. Contact the Dept for addn'l info.
FEE ITEMS (Fee Resolution 11-053 Ef. 7/1/12) FEE QTY/FEE MISC ITEMS
Plan Check Fee:
SuppL PC Fee
PME Plan Check: $0.00
Permit Fee:
Suppl. Insp Fee
PME Unit Fee: $45.00
PME Permit Fee: $45.00
Construction Tar.
Administrative Fee: ]ADMIN $42.00
Work Without Permit? O Yes 0 No $0.00
Advane"I Planning Fees:
Travel Documentation Fee: ITRAVDOC $45.00
Strong Motion Fee: IBSBISNI7CR $0.50 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $1.00
$178.501 $0.00 ` v� gOA)LE $178.50
I «a.
Revised: 01/01/2013
GENERAL PERMIT APPLICATION M E P
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION O
.10300 TORRE AVENUE•CUPERTINO,CA 95014.3255 M I
sc
CUPERTlNO (408)777-3228• FAX(408)777-3333• buildinG(CDCUDertin).OrG MQ
PLUMBING MECHANICAL ELECTRICAL EIMISCELLANFOUS
PROJECT ADDRESS 0_SS7 l— r � iAPN,
h `
OWNERNAME rn PHO J�.11 T� E-MAIL Ogp
V
STREETADDRESS CITY, STATE,ZIP FAX
CONTACT NAME R PHONE �� ,�J 221 E-MAIL
Nd 1
STREETADDRESS NO
4 k �y CITY
,S 9515 FAX
❑ OWNER ❑ OWNER-BUBDER ❑ OWNERAGENr 194ONTPICTOR ❑CONTRACrORAGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT
OONTRACTORNAME ve� LICENSEW1 L( LICENSETYPE � BUS.LIC%
COMPANYNAME E-MAIL FAX !1 qQ r�
E- 1
STREET ADDRESS ` J 1 CITY,STATE,Z� ie ro PHOh O r �Z I "O y \C_
IN
ARCHITECT/ENGEER NAME LICENSE NUMBER �! BUS.LIC#
COMPANY NAME E-MAR. FAX
STREETADDRESS CITY,STATE,ZIP PHONE
USE OF ❑SFD ar DUPLEX ❑ MULTI-FAMD.Y PROJECT IN MIDLAND ❑ YES PROJECT IN ❑YES IS THE BLDG AN ❑YEs
BUILDING: ❑COMN.ERCIAL URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑NO EICHLERHOMEt ❑NO
DESCRIPTION OF WORK
TOTALVALUATION: t5;0U. — ED BY:
By my signature below,I certify to each of the fallowi g: I am the property,owner or authorized agent to act o e pr erty owner's . I have read this
application and the information I have provi Js L I have read the Description of Work and verify itis accurate. I a ee to comyly with all applicable local
ordinances and state laws relating to buil ' g n. I authorize representatives of Cupertino to enter the abo a-idem ed ropef!'y for inspection pu@oses.
Signature of Alplicant/Agenr Date: � I
SUPPLE INFORMATION REQUIRED OFFICE USE ONLY
W
)NCPOVER-THE-COUNTER
y�
F ❑ EXPRESS
Y
U
W ❑ STANDARD
U
L ❑ LARGE
5
❑ MAJOR
—ME—Pd cApp_2011.doc revised 06121111
Building Department
City Of Cupertino
10300 Torre Avenue
Cupertino, CA 95014-3255
Telephone: 408-777-3228
C U P E RT I N O Fax: 408-777-3333
CONTRACTOR/ SUBCONTRACTOR LIST
JOB ADDRESS: tOSSS 01M\Aft yvz�r PERMIT# ' .1 D
OWNER'S NAME: i PHONE# 1,409)
GENERAL CONTRACTOR: V 'e.. e--,Ck BUSINESS LICENSE#
ADDRESS: / 1 A,sW p , a, k- CITY/ZIPCODE: ,7-
*Our municipal code requires all businesses working in the city to have a City of Cupertiuo'business license.
NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTIONS) WILL BE•SCHEDULED UNTIL THE
GENERAL CONTRACTOR AND ALL SUBCONTRA VE.OBTAINED;.AZC-ITY OF CUPERTINO
BUSINESS LICENSE.
I am not using any subcontractors:
S i g n a—tu-r-e Date
Please check applicable subcontractors and complete the foIlowinginformatton
SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE#
Cabinets & Millwork
Cement Finishing -61
Electrical
Excavation
Fencing
Flooring/Carpeting
Linoleum/Wood
Glass/Glazing
r.
Heating
Insulation
Landscaping
Lathing
Masonry
Painting/Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/Contractor Signature Date
wR s .