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10070197 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10300 IMPERIAL AVE CONTRACTOR:RAGHU KUMAR PERMIT NO: 10070197 DEVARAKONDA -vNER'S NAME: RAGHU KUMAR DEVARAKONDA 10300 IMPERIAL AVE DATE ISSUED:07/30/2010 u WNER'S PHONE: 4082184277 CUPERTINO,CA 95014 PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG f- ELECT f- PLUMB F- License Class Lic.# MECH RESIDENTIAL f- COMMERCIAL r Contractor Date I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION: RECESS LIGHTS INSTALL IN HALL&KITCHEN (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:$300 Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. APPLICANT CERTIFICATION APN Number:35719052.00 Occupancy Type: 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 the 180 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 by: ` - Date:7r ,� " -nature Date C 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). � 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. 1 will maintain perfonnance 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 permit is issued. 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 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 thorized agent: become subject to the Worker's Compensation provisions of the Labor Code,I must I J�...•f �� Dater 10 forthwith comply with such provisions or this permit shall be deemed revoked. A — 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.1 agree to comply with all city and county ordinances and state laws relating Lender's Name to building construction,and hereby authorize representatives of this city to enter the above mentioned property for inspection purposes.(We)agree to save Lender's Address unify 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 understand my plans shall be used as public records. 9.18. Licensed Professional Signatur Date a I.0 0 OWNER-BUILDER DISCLOSURE FORM COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO CA 95014-3255 (408)777-3228• FAX(408)777-3333•.wiidin�ta�cu�artinc.orc CUPERTINO Dear Properly Owner(s): An application for a building permit has been submitted in �our name listing yourself as the builder of the property improvements specified at: 5SITERESS ln3OOr -� wp�'��� NBP ��1 gNAME OWNERA DRESS Ib3Db lmPF�tA2- ��'' I1020�C M DESCRIPTION OF WORK: ! L E Pv GF' 1A) �'Tl We are providing you with an Owner-Builder Acknowledgment and Information Verification Form to make you aware of your responsibilities and possible risk you may incur by hiving this permit issued in your name as the Owner-Builder. We will not issue a building permit until you have read, initialed your understanding of each provision,signed, and returned this form to us at our official address indicai ad. An agent of the owner cannot execute this notice unless you,the property owner, obtain the prior approval of the F ermitting authority. OWNER'S ACKNOWLEDGMENT AND VERIFICATION OF INFORMATION (DIRECTIONS:Please read and initial each statement below to signify you understand or verify this information.) &k-1. I 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 acting as an Owner-Builder and am aware of the limits of my insurance coverage for injuries to workers on my property. AA 2. I understand building permits are not required to be signed by property owners unless they are responsible for the construction and are not hiring a licensed Contractor to assume this responsibility. _W. 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 -,licensed Contractor and having the permit filed in his or her name instead of my own. J4. I understand Contractors are required by laws to be licensed and bonded in California and to list their license numbers on permits and contracts. 5. I understand if I employ or t fve hu nd ed dolls other including than Claboor andlmate ials, I may be totage!any Contractors, and the al value of my construction is at leas considered an employer"under state and federal Iew. _Qx6. 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. I understand under California Contractors' :tate License Law, an Owner-Builder who builds single-family d them with the intent to offer them for sale, unless all work is performed by residential structures cannot legally buil tures does not exceed four within any calendar year, or all of the work licensed subcontractors and the number of struc is performed under contract with a licensed genera building Contractor. 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. (%i,nerBui1derForm_2010.doc revised 04/14/10 9. I understand I may obtain more information regarding my obligations,as 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 also understand I may contact the California Contractors'State License Board(CSLB)at 1-800-321-CSLB (2752)or rvww.cslb.ca.gov for more information about licensed contractors. _%:K_10. I am aware of and consent to an Owner-Buil Jer building permit applied for in my name, and understand that 1 am the party legally and financially responsible for proposed construction activity at the site address listed above. 'g1-. 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. i �.12. 1 agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the information I have provided on this form. Licensed coitractors are regulated by laws designed to protect the public. If you contract with someone who does not have a license,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 fir you to understand that if an unlicensed Contractor or employee of that individual or firm is injured while wo Icing 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 status of their workers'compensation.insurance coverage. CONSTRUCTION LENDING AGENCY (DIRECTIONS.Please complete the following constructicn 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: Lenc'er Address: Before a building permit can be Issued,this form muE,t be completed and signed by the property owner and returned to the agency responsible for issuing the pe-mit. Note:A copy of the property owner's driver's license, form notarization, or other verification acceptable to the c,ty may be required to be presented when the permit is issued to verify the property owner's sIgnat Property Owner's Signature: Date: 611.S072-alb --- -- - -- ---------------------- --------- - - . - - - - - - - - '----------------------------------------------- (NOTE: The following Authorization Form is required tot a completed by the property owner only when designating an agent of the property owner to apply for a construction permit for the Owner-Builder). AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF Excluding the Notice to Property Owner,the execution of vvhich I understand is r�y personal responsibility, I hereby authorize the following person(s)to act as my agent(s)to apply for, sign, and file the 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 cf the property owner's driver's license, form notarization, or other verification acceptable to the city may be required to be p esented when the permit is issued to verify the property owner's signature. Property Owner's Signature: Date: OwnerBuilderFonn 2010.doc revised 04/14/10 CITY OF CUPERTINO FEE ESTIMATOR-- BUILDING DIVISION ADDRESS: DATE: REVIEWED BY: APN: BP#: *VALUATION: 1$3,000 'PERMIT TYPE: Mechanical Permit PLA N CHECK TYPE: Alteration /Addition / Repair PRIMARY SFD or Duplexi, APPLICATION 1RMAP6 USE: - TYPE: as 00 3 � APPLIANCE/EQUIP TYPE CAPACITY FEE ID QTY BP FEES Furnace, Forced-Air 1MFP=<100 1 $126 TOTALS: $126.00 Mech.Plan Check 0.0 1 hrs $0.00 , Mech.Permit Fee: 1 MPERMIT Other Mech.Insp. 0.0 hrs $42.00 NOTE: Thesefees are based on the preliminary information available and are on an estimate. Contact the De t or addn'1 info. FEE ITEMS (I'ee Resolution 09-051 E,f: ?/1,109) FEE QTY/FEE MISC ITEMS PME Plan Check: $C.00 PME Unit Fee: $126.00 PME Permit Fee: $42.00 Work Without Permit? Q Yes No $C.00 i' Travel Documentation Fee: ITRA VDOC $42'.00 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $1 .00 SUBTOTALS: $211 .00 $0.00 TOTAL FEE:T $211.00 Revised: 7/27/2010 CITY OF CUPERTINO 4 ITEMS OF 9 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blc: Lot: APN . . . . . . . . : 35719052 . 00 DATE ISSUED. . . . . . . : 07/30/2010 RECEIPT #. . . . . . . . . : BS300011025 REFERENCE ID # . . . : 10070197 SITE ADDRESS 10300 IMPERIAL AVE SUBDIVISION . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . OWNER RA3HU KUMAR DEVARAKONDA ADDRESS 10300 IMPERIAL AVE CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM RAGHU DEVARAKONDA CONTRACTOR . . . . . . . : LIC # *OWNER* COMPANY RAGHU KUMAR DEVARAKONDA ADDRESS 10300 IMPERIAL AVE CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 TELEPHONE . . . . . . . . . FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- ---------- 1BCBSC VALUATION 300 . 00 2 . 00 0 .00 2 . 00 0 . 00 1MFR=<100 UNITS 2 . 00 252 .00 0 . 00 252 . 00 0 .00 1MPERMITFE FLAT RATE 2 . 00 84 . 00 0 .00 84 . 00 0 . 00 1TRAVDOC FLAT RATE 2 . 00 84 . 00 0. 00 84 . 00 0 . 00 ---------- ---------- ---------- ---------- TOTAL PERMIT 422 . 00 0 .00 422 . 00 0 .00 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 301 ROUGH PLUMBING 303 ROUGH MECHANICAL 304 ROUGH ELECTRICAL 501 FINAL ELECTRICAL ENERGY 502 FINAL PLUMBING ENERGY 503 FINAL MECHANICAL ENERGY 504 FINAL BUILDING ENERGY 505 FINAL ELECTRICAL 507 FINAL PLUMBING 508 FINAL MECHANICAL a&-- CITY OF C'UPERTINO CITY OF CUPERTINO GENERAL BUILDING PERMIT APPLICATION FORM APN # C_ : Date: r ° ` ► '' Lj ' �' 09 13 0 2oto Building Address: 10300 1MpEQ( Ar L- Ave . , e-Wep-TT1No , Ch 9ratLl Mailing Address (if different from building address): Are Hazardous Materials being used as part of this project? Yes No HOA: (Exterior work only) Yes ❑ No ❑ If,ies, provide letter from HOA Owner's Name: Phone#: AGOU JeWM A-R rPPV -1ZPkoiu Q00 21$ — u2'17 Contractor: Phone: © � Fax: Contractor License#: Cupertino Business License#: Contact: Phone: Fax: Residential Commercial Job Description: 11'VJ 1*L L F'1) 11V �*L LA K i l OWA/ Building Permit Info: ' Bldg ❑ Elect Plumb ❑ 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: . o .00 Project Size: Express Standard ❑ Large [] Major ❑ Green Building: Please complete relevant portion c f the Green Bu' ding/LEED Checklist & attach it to the application or if applicable, include in plan set & the sheet index. noints Achieved: For help, contact Build it Green at www.builditgrel:n.or Revised 07/14/09