10070198 CITY OF CUPERTIP40 BUILDING PERMIT
BUILDING ADDRESS: 10300 IMPERIAL AVE CONTRACTOR:RAGHU KUMAR PERMIT NO: 10070198
DEVARAKONDA
YER'S NAME: RAGHU KUMAR DEVARAKONDA 10300 IMPERIAL AVE DATE ISSUED:07/30/2010
OWNER'S PHONE: 4082184277 CUPERTINO,CA 95014 PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT r PLUMB
License Class Lic.#
MECH r RESIDENTIAL[_ COMMERCIAL
Contractor Date
I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:NEW ATTIC FURNACE INSTALLED
(commencing with Section 7000)of Division 3 of the Business&Professions **SEE NOTES**
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 Sq.Ft Floor Area:- Valuation:$3000
Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued.
APN Number:35719052.00 Occupancy Type:
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 PERMIT EXPIRES IF WORK IS NOT STARTED
upon the above mentioned property for inspection purposes. (We)agree to save
indemnify and keep harmless the City of Cupertino against liabilities,judgments, WITHIN 180 DAYS OF PERMIT ISSUANCE OR
costs,and expenses which may accrue against said City in consequence of the180 DAYS FROM LAST CALLED INSPECTION.
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• Issued
/�� Date: �'
Iture Date
OWNER-BUILDER DECLARATION RE-ROOFS:
All roofs shall be inspected prior to any roofing material being installed.If a roof is
I hereby affirm that I am exempt from the Contractor's License Law for one of installed without first obtaining an inspection,I agree to remove all new materials for
the following two reasons: inspection.
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, Signature of Applicant: Date:
Business&Professions Code)
I,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business&Professions Code). it ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
I hereby affirm under penalty of perjury one of the following three
declarations: HAZARDOUS MATERIALS DISCLOSURE
I have and will maintain a Certificate of Consent to self-insure for Worker's I have read the hazardous materials requirements under Chapter 6.95 of the
Compensation,as provided for by Section 3700 of the Labor Code,for the California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain
performance of the work for which this permit is issued. compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
I have and will maintain Worker's Compensation Insurance,as provided for by Safety Code,Section 25532(a)should I store or handle hazardous material.
Section 3700 of the Labor Code,for the performance of the work for which this Additionally,should I use equipment or devices which emit hazardous air
contaminants as defined by the Bay Area Air Quality Management District I will
permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
I certify that in the performance of the work for which this permit is issued,I shall Health&Safety Code,Sections 25505,25533,and 25534.
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 Owner authorized agent:
become subject to the Worker's Compensation provisions of the Labor Code,I must A=:L>== Date: 61130/7010
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
APPLICANT CERTIFICATION I hereby affirm that there is a construction lending agency for the performance of work's
I certify that I have read this application and state that the above information is for which this permit is issued(Sec.3097,Civ C.)
correct.I agree to comply with all city and county ordinances and state laws relating Lender's Name
to huilding construction,and hereby authorize representatives of this city to enter
the above mentioned property for inspection purposes.(We)agree to save Lender's Address
i._ mnify 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 ARCHITECT'S DECLARATION
with all non-point source regulations per the Cupertino Municipal Code,Section I understand my plans shall be used as public records.
9.18.
�� '� Date 61 �� 1610 Licensed Professional
Signature
CITY OF CUPERTINO
5 ITEMS OF 9 PERMI'P RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blit: Lot:
APN . . . . . . . . : 35719052 . 00
DATE ISSUED. . . . . . . : 07 /30/2010
RECEIPT #. . . . . . . . . : BS )00011025
REFERENCE ID # . . . : 10 )70198
SITE ADDRESS . . . . . : 10300 IMPERIAL AVE
SUBDIVISION . . . . . .
CITY . . . . . . . . . . . . . . CU:?ERTINO
IMPACT AREA . . . . . .
OWNER RAGHU KUMAR DEVARAKONDA
ADDRESS . . . . . . . . . . : 10:300 IMPERIAL AVE
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
RECEIVED FROM . . . . : RAGHU DEVARAKONDA
CONTRACTOR . . . . . . . : LIC # *OWNER*
COMPANY . . . . . . . . . . : RAGHU KUMAR DEVARAKONDA
ADDRESS . . . . . . . . . . : 10:300 IMPERIAL AVE
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
TELEPHONE . . . . . . . .
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- - --------- ---------- ---------- ----------
1BCBSC VALUATION 3, 000 . 00 2 . 00 0. 00 2 . 00 0 . 00
1BREMFIXT NO. FIXTURES 2 . 00 126 . 00 0 . 00 126 . 00 0 . 00
1BREMRECEP NO. OUTLETS 2 . 00 84 . 00 0 .00 84 . 00 0 . 00
1EPERMITFE FLAT RATE 2 . 00 84 . 00 0 . 00 84 . 00 0 . 00
1TRAVDOC FLAT RATE 2 . 00 84 . 00 0 . 00 84 . 00 0 . 00
----------- ---------- ---------- ----------
TOTAL PERMIT 380 . 00 0. 00 380 . 00 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CREDIT CARD 802 . 00 AMEX
---------------
TOTAL RECEIPT 802 .00
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
304 ROUGH ELECTRICAL 501 FINAL ELECTRICAL ENERGY
505 FINAL ELECTRICAL 512 FINAL HANDI-CAP
CITY OF CUPERTINO
FEE ESTIMATOR-- BUILDING DIVISION
ADDRESS: DATE: REVIEWED BY:
APN: BP#: "VALUATION: $300
PERMIT TYPE: Electrical Permit PLA N CHECK TYPE: Alteration/Addition / Repair
PRIMARYSFD or Duplex `}, APPLICATION 1 REAP11
USE: TYPE:
xW
as
C)
3:
APPLIANCE/EQUIP TYPE CAPACITY FEE ID QTY BP FEES
Fixtures, Lighting 1 BRE MFIXT 1 $63
Recep/Switch/Outlets 1BREHRECEP 1 $42
TOTALS: $105.00
Elec.Plan Check 0.0 hrs $0.00
Elec.Permit Fee: IEPERMIT
Other Elec.Insp. 0.0 hrs $42.00
NOTE: Thesefees are based on the preliminary information<<vailable and are onI an estimate. Contact the Dept-for addn'1 info.
FEE ITEMS (Fee Resolution 09-051 Eff 7,1,,09) FEE QTY/FEE MISC ITEMS
rxr t t
PME Plan Check: $0.00
PME Unit Fee: $105.00
PME Permit Fee: $4 :.00
Work Without Permit? Q Yes No $0.00
Travel Documentation Fee: ITRA VDOC $42.00
Select an Administrative Item
131d�_, Stds Commission Fee: IBCBSC
SUBTOTALS: $19().00 $0.00 TOTAL FEE: $190.00
Revised: 7/27/2010
CITY OF CUPERTINO
FURNACE/AC
CUPEkTiNO PERMIT APPLICATION FORM
APN # � _ �; Date:
01/30 /2410
Building Address:
10300 1fA?491Zt41- ►AvC . o v-pep-myVo C-A 9.5'altA
Owner's Name: Phone#:
P AQA U kU rAjkZ d e vArP-AKb N1t� LU Dig Z 19 —X12.'7'7
Contractor: Phone#: "
Fax#:
Contractor License#: Cupertino Business License#:
Contact: Phone#:
Fax #:
Building Permit Info:
Elect Q Plumb [ Mech
Residential Commercial
Job Description:
IVCw Arn t e- F-UIZNAC-c% WA& I?VS'f*LL6-b
For Residential Installations:
Attic ] 1"floor ❑ 2nd floor ❑
Adhere to minimum setback requirement ❑
For Commercial Installations:
Replacement same weight ❑ Additional weight (structural calcs) ❑
Structural Calculations required for new installation ❑
New installation Planning Approval Required ❑
Cost of Project: Type of nstr (Usage Class):
$ 3000 .o a
Strapped On Plat orm Bondei ❑ New Loca0an r" Replacement
Project Size: Express Standard ❑ Large [] Major❑
Valuation:
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.
Revised 01/07/09
OWNER-BUILDER DISCLOSURE FORM
COMMUNITY DEVELOPMENT DEPARINIENT-BUILDING DIVISION
10300 TORRE AVENUE-CUPERTINO,CA 95014-3255
(408)777-3228- FAX(408)777-3333• uiidinararcuDertinD.DEC
CUPERTINO
Dear Property Owner(s):
An application for a building permit has been submitted in your name listing yourself as the builder of the property
improvements specified at:
SITE ADDRESS APN BP#rQ� �r�
/(33(g) irAPCQlALAr�d'.,CVPFPTI
OWNE NAME OWNER ADDRESS 1o,3o� (M pe R(A L- Pive., c UQCR7 I IVv,CA
cvmlRR kA/v
DESCRIPTION OF WORK:
tM LL � CE S LIG 7 1 A• L - T EN FtJZ- 11V
We are providing you with an Owner-Builder Acknowledgrient and Information Verification Form to make you aware of
your responsibilities and possible risk you may incur by heving this permit issued in your name as the Owner-Builder. We
will not issue a building permit until you have read, in tialed your understanding of each provision,signed, and
returned this form to us at our official address indicat:d. An agent of the owner cannot execute this notice unless
you,the property owner, obtain the prior approval of the p:rmitting authority.
OWNER'S ACKNOWLEDGMENT AND VERIFICATION 3F INFORMATION
(DIRECTIONS:Please read and initial each statement below to signify you understand or verify this information.)
2k 1. 1 understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner-
Builder"building permit that erroneously implies that the property owner is providing his or her own labor and material
personally. I, as an Owner-Builder, may be held liable and subject to serious financial risk for any injuries sustained by
an unlicensed person and his or her employees while working on my property. My homeowner's insurance may not
provide coverage for those injuries. I am willfully actirg as an Owner-Builder and am aware of the limits of my
insurance coverage for injuries to workers on my property.
RIL 2. 1 understand building permits are not requirec to be signed by property owners unless they are responsible for
the construction and are not hiring a licensed Contrai;tor to assume this responsibility.
_%k3. I understand as an"Owner-Builder" I am the responsible party of record on the permit. I understand that I may
protect myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her
name instead of my own.
Q)L 4. 1 understand Contractors are required by law to be licensed and bonded in California and to list their license
numbers on permits and contracts.
_Rt �5. 1 understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the
total value of my construction is at least five hundrec dollars($500), including labor and materials, I may be
considered an"employer"under state and federal lay.
-&v,-6. 1 understand if I am considered an"employer"under state and federal law, I must register with the state and
federal government,withhold payroll taxes, provide workers' compensation disability insurance, and contribute to
unemployment compensation for each"employee." I also understand my failure to abide by these laws may subject
me to serious financial risk.
,7. 1 understand under California Contractors'S-ate License Law, an Owner-Builder who builds single-family
residential structures cannot legally build them with :he intent to offer them for sale, unless all work is performed by
does not exceed four within any calendar year, or all of the work
licensed subcontractors and the number of structures
is performed under contract with a licensed general building Contractor.
&L-8. I understand as an Owner-Builder if I sell the:property for which this permit is issued, I may be held liable for
any financial or personal injuries sustained by any subsequent owner(s)that result from any latent construction
defects in the workmanship or materials.
0�i,nerBuilderFornt 1010.doc revised 04/14/10
$I� I understand I may obtain more information regarding my obligationsas an"employer"from the Internal
Revenue Service,the United States Small Business administration,the California Department of Benefit Payments,
and the California Division of Industrial Accidents. I a[m understand I may contact the California Contractors'State
License Board(CSLB)at 1-800-321-CSLB (2752)or%vww.csib.ca.gov for more information about licensed
contractors.
-Rtc10. 1 am aware of and consent to an Owner-Builder building permit applied for in my name, and understand that I
am the party legally and financially responsible for prc posed construction activity at the site address listed above.
I agree that, as the party legally and financially responsible for this proposed construction activity, I will abide
by all applicable laws and requirements that govern Owner-Builders as well as employers.
��&12. I agree to notify the issuer of this form immeciately of any additions;' deletions, or changes to any of the
inTormation I have provided on this form. Licensed contractors are regulated!by laws designed to protect the public. If
you contract with someone who does not have a licen 3e, the Contractors'State License Board may be unable to
assist you with any financial loss you may sustain as a result of a complaint.'Your only remedy against unlicensed
Contractors may be in civil court. It is also important fc r you to understand that if an unlicensed Contractor or
employee of that individual or firm is injured while working on your property, you may be held liable for damages. If
you obtain a permit as Owner-Builder and wish to hire Contractors, you will be responsible for verifying whether or not
those Contractors are properly licensed and the statuE of their workers'compensation insurance coverage.
CONSTRUCTION LENDING AGENCY .
(DIRECTIONS.Please complete the following constructiot►lending agency information.)
I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued
(Sec 3097 Civ.)
Lender Name: Lendor Address:
Before a building permit can be issued,this form must be completed and signed by the property owner and
_v
returned to the agency responsible for issuing the permit. Note:A copy of the property owner's driver's license,
form notarization, or other verification acceptable to the cite may be required to be presented when the pennit is issued
to verify the property owner's signature.
Property Owner's Signature: Date:
---------------------------------------------------
gOTE Th pollw�wner to apply for a construction pen nit for the
( g property owner only when designating an
agent of the roe Owner-Builder).
AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF
Excluding the Notice to Property Owner, the execution of%A hich I understand is my personal responsibility, I hereby
authorize the following person(s)to act as my agent(s)to apply for, sign, and file4he documents necessary to obtain an
Owner-Builder Permit for my project.
Scope of Construction Project(or Description of Work):
Project Location or Address:
Name of Authorized Agent: Tel No
Address of Authorized Agent:
I declare under penalty of perjury that I am the property owner for the address listed above and I personally filled out the
above information and certify its accuracy. Note:A copy of he property owner's driver's license, form notarization, or other
verification acceptable to the city may be required to be presented when the permit is issued to verify the property owner's
signature.
Property Owner's Signature: Date:
OHmerBuilderForns 1010.doc revised 04114/10