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11090114CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 7576 SHADOWHILL LN OWNER'S NAME: SREEHARI NARASIMHAIAH OWNER'S PHONE: 4084463361 LICENSED CONTRACTOR'S DECLARATION License Class C3(, Lie. #/ 3 / d�3y y Contractor p t J f A Date_? ti 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 Sign I Signature JI` Date 1- OWNER -BUILDER DECLARATION i ...:reby 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). CONTRACTOR: GOGO ROOTER PERMIT NO: 11090114 2530 BERRYESSA RD STE 509 DATE ISSUED: 09/19/2011 SAN JOSE, CA 95132 PHONE NO: (408) 282-7026 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 BUILDING PERMIT INFO: BLDG f— ELECT PLUMB MECH F RESIDENTIAL COMMERCIAL JOB DESCRIPTION: REPLACE WATER SUPPLY LINE, BACKFLOW DEVICE 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 'ng of this permit. Additionally, the applicant understands and will comply all non -point source regulations per the Cupertino Municipal Code, Section 9.18. Signature Date Sq. Ft Floor Area: I Valuation: $3459 APN Number: 36224030.00 1 Occupancy Type: PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST 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. Ow'zed nt: -7,//-9-// _ Date: CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of mrk'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 6 ITEMS OF 6 CITY OF CUPERTINO PERMIT RECEIPT Sec: Twp: Rng: Sub: Blk: Lot: APN ........: 36224030.00 DATE ISSUED.......: 09/19/2011 RECEIPT #......... BS000014793 REFERENCE ID # ...: 11090114 SITE ADDRESS 7576 SHADOWHILL LN SUBDIVISION ...... CITY .............. CUPERTINO IMPACT AREA ...... OPERATOR: patg COPY # : 1 OWNER SREEHARI NARASIMHAIAH ADDRESS 7576 SHADOWHILL LN CITY/STATE/ZIP ...: CUPERTINO, CA 95014-5052 RECEIVED FROM ....: PAUL LEE CONTRACTOR .......: DUARTE TADEU LIC # 28801 COMPANY GOGO ROOTER ADDRESS ..........: 2530 BERRYESSA RD STE 509 CITY/STATE/ZIP ...: SAN JOSE, CA 95132 TELEPHONE (408) 282-7026 FEE ID UNIT QUANTITY AMOUNT PD -TO -DT THIS REC ---------- NEW BAL - ---------- lADMIN ------------- HOURS ---------- 1.00 ---------- 41.00 ---------- 0.00 41.00 0.00 1BCBSC VALUATION 3,459.00 1.00 0.00 1.00 0.00 1BSEISMICR VALUATION 3,459.00 0.50 0.00 0.50 0.00 1PATMOBF UNITS 1.00 65.00 0.00 65.00 0.00 1PPERMITFE FLAT RATE 1.00 44.00 0.00 44.00 0.00 1TRAVDOC FLAT RATE 1.00 44.00 0.00 ---------- 44.00 ---------- 0.00 ---------- TOTAL PERMIT ---------- 195.50 0.00 195.50 0.00 METHOD OF PAYMENT ----------------- CREDIT CARD TOTAL RECEIPT : AMOUNT --------------- 195.50 --------------- 195.50 REFERENCE NUMBER -------------------- #26997 SE -VISA VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ----------------------- 301 ROUGH PLUMBING 507 FINAL PLUMBING CITY OF CUPERTINO FEE ESTIMATOR - BUILDING DIVISION 7ADRESS: 7576 shadow hill In. DATE: 09/19/2011 REVIEWED BY: bobs. : BP#: "VALUATION: $3,459 "PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration /Addition /Repair PRIMARY PENTAMATION USE: SFD or Duplex PERMIT TYPE: WORK replace water supply line backflow device. SCOPE 1RP13F APPLIANCE / EQUIP TYPE FEE ID �.� �••• »•- QTY/FEE QTY UNITS BP FEES Vacuum Backflow 1 PATMOBF 1 # $65 PME Unit Fee: $65.00 PME Permit Fee: $44.00 Administrative Fee: (ADMIN $41.00 Work Without Permit? Q Yes (j) No $0.00 TOTALS: i Travel Documentation Fee: ITRA VDOC $44.00 $65.00 $0.50 NOTE: This estimate does not tnctuae fees aue tuinner "cp,3 11.C.. "ULLl �• �• ��••••»• . -- - __, _ ___ _ These ees are hasea on the rettmtnar to arrnuit" FEE ITEMS (Fee Resolution 11-053 Elf 1) uvuasu�ac u.� FEE �.� �••• »•- QTY/FEE ��--•-____. _________ ___ MISC ITEMS PME Plan Check: $0.00 PME Unit Fee: $65.00 PME Permit Fee: $44.00 Administrative Fee: (ADMIN $41.00 Work Without Permit? Q Yes (j) No $0.00 i Travel Documentation Fee: ITRA VDOC $44.00 Strong, Motion Fee: IBSEISMICR $0.50 Select an Administrative Item 131&4 Stds Commission Fee: IBCBSC $1.00 SUBTOTALS; $195.50 $0.00 TOTAL FEE: n _. _-_ $195.50 ^^I^/14 4 1\GV1Q,U- . WV W -1—v . CUPERTINO // f Cq Q / ` � GENERAL PERMIT APPLICATION MEP COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 MISC (408) 777-3228 • FAX (408) 777-3333 • building(a�cupertino.org ❑ OWNER ❑ OWNER-BUII.DER ❑ OWNER AGENT E CONTRACTOR El CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER 11 DEVELOPER 11 TENANT CONTRACTOR NAME /� LICENSE NUMBER CeJ�d .� i, LICENSE TYPE /� 7� BUS. LIC # (� I r, 7' E-MAIL FAX COMPANY NAME FS -1 7 STREET ADDRESS . C, ? �Q% CITY, STATE, ZIP t_A Tu / / S13 G PHONE M4 JMBING El MECHANICAL ❑ELECTRICAL ❑MISCELLANEOUS PROJECT ADDRESS 5� / `_ A f V (�%I 0 • I 1 APN # % 4 � 1-1-11 � OWNER NAME BUS. LIC # PHONE 3 3 bI (J E-MAIL COMPANY NAME' iV` ' Y t ! STREET ADDRESS S Rrt '4` 1►N CITY, STATE, ZIP �/ 4i✓�I 7 fG�/ FAX CONTACT NAME PROJECT IN ❑ YES ❑ NO PHONE E M� STREET ADDRESS URBAN INTERFACE AREA ❑ NO CITY, STATE, ZIP F ❑ OWNER ❑ OWNER-BUII.DER ❑ OWNER AGENT E CONTRACTOR El CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER 11 DEVELOPER 11 TENANT CONTRACTOR NAME /� LICENSE NUMBER CeJ�d .� i, LICENSE TYPE /� 7� BUS. LIC # (� I r, 7' E-MAIL FAX COMPANY NAME FS -1 7 STREET ADDRESS . C, ? �Q% CITY, STATE, ZIP t_A Tu / / S13 G PHONE TOTAL VALUATION: 3 q5 8 Rb I RECEIVED BY: / [J o�. By my signature below, I certify to each of the following: I am the property owner or authorized agent to act on the property owners behalf. I have read this application and the information I have provided is correct., 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 building cons ction. I uthorize representatives of no to enter the above -idem /ty for inspection puiposes. Signature of Applicant/Agent: �� ✓i, Date: SUPPLEMENTAL INFORMATION REQUIRED OFFICE.UE ONLY OVER-THE-COUNTER a ❑ EXPRESS Y U w ❑ STANDARD T U ❑ LARGE c. ❑ MAJOR MEPMiscApp_2011.doe revised 06121111 ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS. LIC # FAX COMPANY NAME' E-MAIL PHONE STREET ADDRESS CITY, STATE, ZIP USE OF or DUPLEX ❑ MULTI -FAMILY PROJECT IN WILDLAND ❑ YES PROJECT IN ❑ YES ❑ NO IS THE BLDG AN EICHLER HOME? ❑YES ❑ NO BUILDING: [3 COMMERCIAL URBAN INTERFACE AREA ❑ NO FLOOD ZONE DESCRIPTION OF WORK t t ;�rJ� �. f��J S•. e ^ Q S t ` ,rt 11 V 3 /�ry TOTAL VALUATION: 3 q5 8 Rb I RECEIVED BY: / [J o�. By my signature below, I certify to each of the following: I am the property owner or authorized agent to act on the property owners behalf. I have read this application and the information I have provided is correct., 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 building cons ction. I uthorize representatives of no to enter the above -idem /ty for inspection puiposes. Signature of Applicant/Agent: �� ✓i, Date: SUPPLEMENTAL INFORMATION REQUIRED OFFICE.UE ONLY OVER-THE-COUNTER a ❑ EXPRESS Y U w ❑ STANDARD T U ❑ LARGE c. ❑ MAJOR MEPMiscApp_2011.doe revised 06121111 CUPERTINO CONTRACTOR / SUBCONTRACTOR LIST Building Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014-3255 Telephone: 408-777-3228 Fax: 408-777-3333 JOB ADDRESS: —757,4 SkAdd : d C OWNER'S NAME: SA4f N Rcs; Q • n„14 '' q 1 PERMIT # PHONE # GENERAL CONTRACTOR: Ga , BUSINESS LICENSE # ADDRESS: Zr CITY/ZIPCODE: *Our municipal code requires all businesses working in the city to nave a t -Ary or uperuuu uumlwe 11-113. 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. —� --� y,/rr / I am not using any subcontractors: Signature Date Please check applicable subcontractors and complete the following information: Owner / Contractor Signature Date 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 lastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile Owner / Contractor Signature Date