09120131 CITY OF CUPERTI:vO BUILDING PERMIT
BUILDING ADDRESS: 10541 LARRY WAY CONTRACTOR:GOPU RAMALINGAM PERMIT NO:09120131
OWNER'S NAME: GOPU RAMALINGAM 10541 LARRY WAY DATE ISSUED: 12/21/2009
VNER'S PHONE: 4082167699 CUPERTINO CA, 95014-2034 PHONE NO:
L7 LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL COMMERCIAL
License Class Lic.# REPLACE LAUNDRY SINK-PLUMBING
Contractor Date
1 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.
�'J►' iii '�ia YI
1 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:$200
1 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:31602019.00 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 relatin,' 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 LAST CALLED INSPECTION.
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 Issued by: Date:
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18.
RE-ROOFS:
Signature Date All roofs shall be inspected prior to any roofing material being installed. If a roof is
_ installed without first obtaining an inspection,1 agree to remove all new materials for
inspection.
OWNER-BUILDER DECLARATION
` Signature of Applicant:_ Date:
1 hereby affirm that 1 am exempt from the Contractor's License Law for one c f
the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
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 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 1 use equipment or devices which emit hazardous
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 1
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 25505,25533,and 25534.
Section 3700 of the Labor Code,for the performance of the work for which this
Owner or authorized agentx rA Awyll✓�� Date:___
permit is issued.
1 certify that in the performance of the work for which this permit is issued,1 shall
not employ any person in any manner so as to become subject to the Worker's
CONSTRUCTION LENDING AGENCY
Compensation laws of California. If,after making this certificate of exemption,1
become subject to the Worker's Compensation provisions of the Labor Code,I mu;t 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,_
1 certify that I have read this application and state that the above information is
correct. 1 agree to comply with all city and county ordinances and state laws relatir g
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes.(We)agree to save ARCHITECT'S DECLARATION
i^demnify and keep harmless the City of Cupertino against liabilities,judgments,
:,and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records.
',...ming 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.
Da
Signa[ur te 2J12"o
�
OWNER-BUILDER VERIFICATION
1. (Check one) I or my immediate family (F arent,spouse or child) will perform:
A. ✓ All the work authorh:ed by this permit
B. — A portion of the work
C. _ None of the work
If B or C is checked,complete 2 or 3 below.
2. A state licensed contractor will'be hired to do:
A. _ All of the work
B. _ A portion of the wor:c (complete section below)
Contractor Address/City Phone # State License # Type of work to
be p erformed
3. _ I will utilize unlicensed person(s) o her than my immediate family to perform all or
portions of the authorized work. I understand that I may be an employer(see reverse side). A
Certificate of Insurance covering workers' compensation must be on file at the City of
Cupertino Building Department office.
PersorVFirm Address/City Phone Number Type of work to be
performed
...................................................................................................................................................
I declare under penalty of perjury that the above is true and correct. I have read and understand the
Owner-Builder Information(reverse side).
Date: 19-
Property Owner's Signature:
Job Address: lo
si 41 ( )-w-y-I/V&4 �f F_- L-(f d C/ Permit#
Any changes to the information provided on this form shall be submitted to the City of Cupertino Build
Department.
CITY OF CUPERTINO
6 ITEMS OF 17 PERMI" RECEIPT OPERATOR: SylviaM
COPY # 1
Sec: Twp: Rng: Sub: B11:: Lot:
APN . . . . . . . . : 316-02019 . 00
DATE ISSUED. . . . . . . : 12,21/2009
RECEIPT #. . . . . . . . . BS000009451
REFERENCE ID # . . . : 09/20131
SITE ADDRESS . . . . . : 10541 LARRY WAY
SUBDIVISION . . . . . .
CITY CU:?ERTINO
IMPACT AREA . . . . . .
OWNER GO:?O RAMALINGAM
ADDRESS 10.541 LARRY WAY
CITY/STATE/ZIP . . . : CU:?ERTINO CA, 95014-2034
RECEIVED FROM . . . . : GO:?U RAMALINGAM
CONTRACTOR . . . . . . . : LIC # *OWNER*
COMPANY . . . . . . . . . . : GO?O RAMALINGAM
ADDRESS 10541 LARRY WAY
CITY/STATE/ZIP . . . : CU?ERTINO CA, 95014-2034
TELEPHONE . . . . . . . .
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- - --------- ---------- ---------- ----------
1BCBSC VALUATION 200. 00 1 . 00 0 . 00 1 . 00 0 . 00
1BPTRAP NO OF TRAPS 1 . 00 8 . 00 0 . 00 8 . 00 0 .00
1BSEISMICR VALUATION 200. 00 0 .50 0. 00 0 . 50 0 . 00
1PPERMITFE FLAT RATE 1 . 00 42 . 00 0 . 00 42 . 00 0 . 00
1PRSEWER UNITS 1 . 00 21 .00 0 . 00 21 . 00 0 . 00
1TRAVDOC FLAT RATE 1 . 00 42 . 00 0 . 00 42 . 00 0 . 00
- --------- ---------- ---------- ----------
TOTAL PERMIT 114 .50 0 . 00 114 . 50 0 . 00
t
} ` CITY OF ��UPERTINO
CITY OF
CUPEf�TiNO GENERAI-d BUILDING
PERMIT APPLICATION FORM
oq 1 z. o ► -31
APN# 02 9. Date: 9 / 2 2- 9,�q
Building Address. 1054- 1, �� y W `r C,,i Pf f7/ " f OA 95019
Mailing Address (if different from building address):
Are Hazardous Materials being used as part of this project? Yes No Er
HOA: Exterior work only) Yes ❑ No [ �If es, provide letter from HOA
Owner's Name: Phone#:
Contractor: Phone:
0 Fax:
Contractor License#:
Cupertino Business License#:
Contact: Phone:
Fax:
Residential Commercial
Job Description: rY vim--0 1)4LY P Vvrr11P/tJA VVZ
Building Permit Info:
Bldg �'r Elect ❑
Plumb ffr Mech ❑
Type of Construction (Usage Class): Occupancy Type:
1-A, 1-B ❑ II/III/V-A ❑ II/III B, IV-HT, V-B
Valuation: Square Footage:
Project Size: Ex ress R-- an d ❑ Laz c ❑ Mai or ❑
Green Building: Please complete relevant portion of the Green Building/LEED Checklist & attach it
to the application or if applicable, include in plan set& the sheet index.
Points Achieved:
For help, contact Build it Green at www.builditg reen.or
Revised 07/14/09
CITY OF Lr.UPERTINO
Cin OF GENERAL BUILDING APPLICATION
CUPEf�T1N0
FEE SCHEDULE
Quantity/Sf Fee ID Fee Des,-.ription Fee Permit Type
Group 1GENRES or
1GENCOM
1STUCOAP Stucco Applications (up to 400 sf) B
additional stucco application
1 WINREP Replacement windows/sliding glass B
door (ea 8 windows)
1WINMEWSTR New Window-structural shear B
wall/masonry(includes plan ck fee)
IEPERMITFEE Electrical Permit Fee E
1 MPERMITFEE Mechani-,al Permit Fee M
f 1 PPERMITFEE Plumbin,;Permit Fee P
IELCPLNCK Stand Alone Electric Pln Ck(hourly) E
I MECPLNCK Stand A]one Mechanical Pln Ck(hrly) M
1PLMBLNCK Stand Alone Plumbing Pln Ck(hrly) P
1 STPLNCK-(3 Hr Min Standarc.Plan Check (when no E/M/P) B
when not over counter) hourl -s Land alone
1BCBSC Cal Bldj; Standards Commission Fee B ALL PERMIT
TYPES
1BSEISMICR Seismic Residential B
1BSEISMICO Seismic Commercial B
J 1 TRAVDOC Travel &Documentation B
1BUSLIC Business License B
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