13030163CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 18840 NEWSOM AVE CONTRACTOR: PHAN CONSTRUCTION PERMIT NO: 13030163
CO INC
OWNER'S NAME: SINGAMREDDY KARUNAKAR R
OWNER'S PHONE: 4082428350
❑ LICENSED CONTRACTOR'S DECLARATION
License Class_ Lie. #� S�
Contractor 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.
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.
Signatu!,e,r A_ Date
❑ 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)
I, 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
870 S WOLFE RD
SUNNYVALE, CA 94086
JOB DESCRH'TION: RESIDENTIAL
TEMPORARY POWER POLE
Sq. Ft Floor Area:
DATE ISSUED: 03 /28/2013
PHONE NO: (408)737 -8323
Valuation: $200
APN Number: 37530019.00 1 Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROA43VOr CALLED INSPECTION.
Date: A2 $
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 authorizedda�t:� -� —/
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
GENERAL PERMIT APPLICATION MER
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
�( .10300 TORRE AVENUE • CUPERTI NO, CA 950143255
CUPEuRTINO ( 408) 777 -3228 • FAX ( 408) 777 -3333 • building(c cuDertino.org MISC
❑ PLUMBING ❑ MECHANICAL XFLFCTRICAL ❑ MISCELLANEOUS
PROJECT ADDRESS
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❑ ONNNER ❑ OWNER - BUILDER ❑. OWNER AGENT
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NTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME
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ARCHITECT/ENGINEER NAME
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CITY, STATE, ZIP
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USE OF SFD or DUPLEX ❑ MULTI - FAMILY
PROJECT IN WV LAND ❑ YES
PROJECT IN El YES
IS TIM BLDG AN ❑ YES
BUILDING: ❑COMMERCIAL
URBAN INTERFACE AREA NO
FLOOD ZONE ANIO
EICHLER HOME? O
DESCRIPTION OF WORK formir
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TOTAL VALUATION: Woo.
RECENED 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 with all applicable local
ordinances and state laws relating to buildin co truction. au on rei3resentanves of Cupertino to enter the above - identified property for inspection pu3poses.
Signature of Applicant/Agent:
Date:
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SUP EME AL 1NORION UIRED OFFICE USE ONLY
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MEPMiscApp_201 Ldoc revised 06121111
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CITY OF CUPERTINO
FEE ESTIMATOR — BUILDING DIVISION
APPLIANCE / EQUIP TYPE
ADDRESS: 18840 NEWSOM AVE
DATE: 03/28/2013
REVIEWED BY: MELISSA
UNITS
APN: 375 30 019
BP #:
"VALUATION:
$200
*PERMIT TYPE: Electrical Permit
PLAN CHECK TYPE: Alteration / Addition / Repair
PRIMARY
Sf=D or Duplex
USE:
$45
PENTAMATION
PERMIT TYPE: 1 REAP14
WORK
TEMPORARY POWER POLE
SCOPE
APPLIANCE / EQUIP TYPE
FEE ID
QTY/FEE
QTY
UNITS
BP FEES
Temporary Power
1ERT <200
100
Amps
$45
Perrnil Fee:
.Suppl. Insp F,ee
PME Unit Fee:
$45.00
PME Permit Fee:
$45.00
Consiruction Tax:
,kfech. Plan Check
V1, ch. Permit f ce:
Other ,Wech. Insp. EIF�
A ,fech. Insp. Fee.-
Plumb. Plan Check
Plumb. Permit Fee:
Other Plumb Insp.
Plumb. Insp. Fee:
Elee. Plan Check 10.0 1 hrs $0.00
Elec. Permit Fee: IEPERMIT
Other Elec. Insp. El hrs $45.00
Elec. Insp. Fee.,
9TE: This estimate does not include fees due to other Departments (Le. Planning, Public Works, Fire, Sanitary Sewer District, Schoc
District, etc). Thesefees are based on the preliminary information available and are only an estimate. Contact the Dept_lor addn7 Info.
FEE ITEMS (Fee Resolution 11 -053 E . 711112 ) ,
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee:
Suppl. PC Fee
PME Plan Check:
$0.00
Perrnil Fee:
.Suppl. Insp F,ee
PME Unit Fee:
$45.00
PME Permit Fee:
$45.00
Consiruction Tax:
Administrative Fee: IADMIN
$42.00
Work Without Permit? 0 Yes 0 No
$0.00
Advanc'•ed Planning h`ees:
Travel Documentation Fee: 1TRAVDOC
$45.00
Strom Motion Fee: IBSEISMICR
$0.50
Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC
$1.00
$178.50
$0.00 .. �E s
$178.50
Revised: 01/01/2013