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10120013I CITY OF CUPERTINO BUILDING PERMIT I BUILDING ADDRESS: 7475 DE LA FARGE DR I CONTRACTOR: I PERMIT NO: 10120013 I OWNER'S NAME: SIVARAM SURYANARAYAN LIet;,f Ht W I DATE ISSUED: 12/02/2010 OWNER'S PHONE: 4082572768 L LICENSED CONTRACTOR'S DECLARATION License Class y33 ko 7-- Lic. # G ^ 3 6 Contractor C, ow oyya.'Y— Date &10 I hereby affirm that I am licensed under the provisi ns 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 ich this permit is issued. APPLICANT CERTIFICATION I certify that I have read this application and state that the above info ation is correct. I agree to comply with all city and county ordinances and s to laws relating to building construction, and hereby authorize representatives of thi 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 -points urce regulations per the Cupertino Municipal Code, Section 9.18. / Date / / a / 1O OWNER -BUILDER DECLARATION I hereby 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) 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, c(-ts, 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 PHONE NO: BUILDING PERMIT INFO: BLDG F ELECT r— PLUMB r— MECH r— RESIDENTIAL r— COMMERCIAL r— JOB DESCRIPTION: GAS PIPE FROM METER TO KITCHEN STOVE RANGE -DEDICATED Sq. Ft Floor Area: I Valuation: $450 APN Number: 35926018.00 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: �'s�"`— -. Dater 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. Own r authorized ager Date��, 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 CITY OF CUPERTINO FFF F-STIMATOR - BUILDING DIVISION APPLIANCE / EQUIP TYPE ADDRESS: 7475 de la farge dr. DATE: 12/0212010 REVIEWED BY: bobs. UNITS APN: I BP#: *VALUATION: 1$450 *PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration / Addition / Repair PRIMARY SFD or Duplex -1-0 PENTAMATION 1 RPGAS USE: i"11. ['1 0OR h., fL PERMIT TYPE: suppi" 111sp I -'L'(.' F71 WORK PME Unit Fee: SCOPE PME Permit Fee: APPLIANCE / EQUIP TYPE FEE ID Plumb. Plan Check 1 0.0 hrs $0.00 QTY UNITS BP FEES I !"7e,' Permit Piping, Gas <=4 Outlets 1PGASRES oiho' 111""CIC , h'y' 1 # $63 Perinit suppi" 111sp I -'L'(.' F71 PME Unit Fee: $63.00 PME Permit Fee: $42.00 C011SWIR'l I On 7-CLV Ref -tete Fce: Work Without Permit? 0 Yes E) No $0.00 TOTALS: L $63.001 Strong Motion Fee: IBSEISAffCR 7% rZI Iry. x,,..11 fl— rglym;"ariy i"fnrmatin" available and are only an estimate. Contact the Dept for addn'l into. FEE ITEMS (Fee Resolution 09-051 E'. 7.,"1/10) FEE Plumb. Plan Check 1 0.0 hrs $0.00 ChL'Ck P/an Cllcck 1"Ce: IPlumb. Permit Fee: ]PPERACT I !"7e,' Permit 01hef. h-l.yp. F Other Plumb Insp. 0.0 hrs $42.00 oiho' 111""CIC , h'y' 4";- 1-'Ic( . Imp. FLV - 7% rZI Iry. x,,..11 fl— rglym;"ariy i"fnrmatin" available and are only an estimate. Contact the Dept for addn'l into. FEE ITEMS (Fee Resolution 09-051 E'. 7.,"1/10) FEE QTY/FEE MISC ITEMS P/an Cllcck 1"Ce: sitppl, P(" Fec —T PME Plan Check: $0.00 Perinit suppi" 111sp I -'L'(.' F71 PME Unit Fee: $63.00 PME Permit Fee: $42.00 C011SWIR'l I On 7-CLV Ref -tete Fce: Work Without Permit? 0 Yes E) No $0.00 Travel Documentation Fee: I TRA VDOC $42.00 Strong Motion Fee: IBSEISAffCR $0.50 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $1.00 SUBTOTALS: $148.501 $0.00 TOTAL FEE: 1 $148.501 Revised: 11/08/2010 5 ITEMS OF 6 CITY OF CUPERTINO PERMIT RECEIPT Sec: Twp: Rng: Sub: Blk: Lot: APN ........: 35926018.00 DATE ISSUED.......: 12/02/2010 RECEIPT #......... BS000012130 REFERENCE ID # ...: 10120013 SITE ADDRESS .....: 7475 DE LA FARGE DR SUBDIVISION ...... CITY CUPERTINO IMPACT AREA ...... OWNER ............: SIVARAM SURYANARAYAN ADDRESS ..........: 7475 DE LA FARGE DR CITY/STATE/ZIP ...: CUPERTINO, CA 95014 OPERATOR: patg COPY # : 1 RECEIVED FROM ....: CLEAR DRAIN PLUMBIN CONTRACTOR TBD - TO BE DETERMINED LIC # 00096 COMPANY ..........: TBD - TO BE DETERMINED ADDRESS .......... CITY/STATE/ZIP ...: , TELEPHONE ........ FEE ID UNIT QUANTITY AMOUNT PD -TO -DT THIS REC ---------- NEW BAL ---------- ---------- 1BCBSC ------------- VALUATION ---------- 450.00 ---------- 1.00 ---------- 0.00 1.00 0.00 1BPGAS OULETS 1.00 63.00 0.00 63.00 0.00 1BSEISMICR VALUATION 450.00 0.50 0.00 0.50 0.00 1PPERMITFE FLAT RATE 1.00 42.00 0.00 42.00 0.00 1TRAVDOC FLAT RATE 1.00 42.00 0.00 42.00 ---------- 0.00 ---------- TOTAL PERMIT ---------- 148.50 ---------- 0.00 148.50 0.00 VOICE ID DESCRIPTION -------- ---------------------------- 202 UNDERFLOOR PLUMBING VOICE ID DESCRIPTION -------- ---------------------------- 301 ROUGH PLUMBING 506 GAS TEST 507 FINAL PLUMBING CITY OF CUPEkTINO CITY OF CUPERTINO REPIPE/SEWER/MAIN SERVICE PERMIT APPLICATION FORM APN #�5 9 � � O � Date: 1- Building Address: % Fee Group O er's Name: tJ rk Ah A-✓'4� /� Jh�rAr� Phone #: , 'lam - �S`7 -)-We Contracto : Phone #: ?f S 3 �Y ��P✓ pTAi� LUf,,IS Fax #: Contact: Phone #: L�oe Commercial re -pipe per fixture P 1CPRP Fax #: Contractor License #: b-3 3�-- Commercial Gas Piping System 1-4 Outlets Cupertino Business License #: Job Description: rk �' c I e. L,4 � P C �r-- �., ,,e v" t- Residential Commercial ❑ Valuation: B Project Size: Express . - Standard ❑ Large Major ❑ Green Building: Please complete relevant portion of the Green Building Checklist & attach it to the application or if applicable, include in plan set & the sheet index. P Green Building Points: Quantity Fee ID Fee Description Fee Group Permit Type 1PCSEWER Commercial building sewer/sanitary sewer P 1CPSS 1BPREPIPE Commercial re -pipe per fixture P 1CPRP 1 PGASCOM Commercial Gas Piping System 1-4 Outlets P 1BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT TYPES 1 BSEISMICOM Seismic Commercial P Revised 01/07/09