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10040157CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 22931 STONEBRIDGE ST CONTRACTOR: VEENA K & KARTHIK L PERMIT NO: 10040157 OWNER'S NAME: VEENA K & KARTHIK L .,WNER'S PHONE: 4082215207 ❑ LICENSED CONTRACTOR'S DECLARATION License Class Lic. # Contractor Date 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 9.18. Signature, Date OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: 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) 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 ^,)n the above mentioned property for inspection purposes. (We) agree to save mnify and keep harmless the City of Cupertino against liabilities, judgments, .,,,sts, 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 9.18. (\ k Y,' Signature JC / Date 22931 STONEBRIDGE ST I DATE ISSUED: 04/26/2010 CUPERTINO CA, CA 95014-5640 1 PHONE NO: JOB DESCRIPTION: RESIDENTIAL U COMMERCIAL CHANGE OUT KITCHEN COUNTERTOPS, NEW CABINETS NO (M,E,P)'S Sq. Ft Floor Area: I Valuation: $20000 APN Number: 34213023.00 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 25A05,2553�3, and 25534. Owner or authorized agent: 99�/� ' 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 ARCHITECT'S DECLARATION I understand my plans shall be used as public records. Licensed Profess 5 ITEMS OF 5 CITY OF CUPERTINO PERMIT RECEIPT Sec: Twp: Rng: Sub: Blk: Lot: APN ........: 34213023.00 DATE ISSUED.......: 04/26/2010 RECEIPT #......... BS000010266 REFERENCE ID # 10040157 SITE ADDRESS 22931 STONEBRIDGE ST SUBDIVISION ...... CITY CUPERTINO IMPACT AREA ...... OPERATOR: SylviaM COPY # : 1 OWNER VEENA K & KARTHIK L ADDRESS 22931 STONEBRIDGE ST CITY/STATE/ZIP CUPERTINO CA, CA 95014-5640 RECEIVED FROM VEENA KRISHNAMURTHY CONTRACTOR LIC # *OWNER* COMPANY VEENA K & KARTHIK L ADDRESS 22931 STONEBRIDGE ST CITY/STATE/ZIP CUPERTINO CA, CA 95014-5640 TELEPHONE ........: FEE ID UNIT QUANTITY AMOUNT PD -TO -DT ---------- THIS REC NEW BAL ---------- 1BCBSC ------------- VALUATION ---------- 20,000.00 ---------- 1.00 0.00 1.00 0.00 0.00 1BPFIXTURE NO OF FIXTURE 1.00 8.00 0.00 8.00 2.00 0.00 1BSEISMICR VALUATION 20,000.00 2.00 0.00 0.00 42.00 0.00 1PPERMITFE FLAT RATE 1.00 42.00 42.00 0.00- 1TRAVDOC FLAT RATE 1.00 ---------- - -42_00 ----0_00 ---------- 95.00 0.00 95.00 0.00 TOTAL PERMIT METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- ----- CHECK 95.00 199 --------------- TOTAL RECEIPT 95.00 CITY OF CITY OF CUPERTINO its ADDITION/REMODEL C U P E RT I N O PERMIT APPLICATION FORM APN # 023 •lam Date: , 02& • oa© I C) Is a 2° unit being added? Yes ] No W If yes, please fill out the permit application for 2° unit. Building Address: aQ1 931 ST ©N Mailing Address (if different from building address): �j (� J�A� �7 T) qq © N - - "I' -C Owner's Name: 1�� NN KKK �N N Q M VRT A 1 (kr\C1 Phone #: 409 a a 1,� 2 U� l<A� (_AK H "1NAr2R �P�/ o a S i a 1 Contractor: Phone #: Olo Fax #: Contractor License #: Cupertino Business License #: Contact: Phone #: Fax #: Building Permit Info: Plumb. ® Mech. ❑ Hillside Bldg. El Elect. El Job Description: Addition -What is being added?(Be Specific): What is being remodeled (not including addition)? K(icv c ,�uA4tph) f10_AM0J01Q f o t� NO ,cam (nn Sa-M2 We <• N o � Remodel Includes Re -Roof- Yes ❑ No 0 If yes list number of squares Remodel Includes Structural: Yes ❑ No 1Z Do you have the pre -application planning approval? Yes ❑ No ❑ N 1i If yes, please provide a copy of your planning approval letter. Planners name: Square Footage: V) 0 �j p Addition: Porch: Deck: Garage: Detached Attached Remodel: Kitchen Bath Other Type of Construction (Usage Class): Occupancy Type: : I -A, I -B ❑ II/III/V-A ❑ II/III B, IV -HT, V -B (/ r_ Valuation: a0f Coo Please check this box if the project is a second -story addition ❑ Project Size: Express ❑ Standard ❑ Lar e ❑ Major ❑ Please complete relevant portion of the Green Building Checklist & attach it to the application or if applicable, Green Building Points Achieved: include in plan set & the sheet index. ***For Office Use Only*** Revised 07/06/09 Over -the -Counter ❑ CITY OF CITY OF CUPERTINO ADDITION/REMODEL CUPERTINO FEE SCHEDULE Quantity Sq Ft Fee. ID Fee Description Fee Group Permit Type ADDITIONS 1R3SFDADD I PLLONGRNGR Long Range Planning/Residential PL 1 R3INSP Dwellings Inspections B I R3PLNCK Dwellings plan check B I R3REPINSP Dwellings Repeat Inspection B 1 R3REPPLNC Dwellings Repeat Plan Check B 1 R3HINSP Dwellings Hillside inspection B IR3HPLNCK Dwellings Hillside plan check B 1 R3HREINSP Dwellings Hillside Repeat Inspection B 1 R3HREPLNC Dwellings Hillside Repeat Plan Check B 1 R3ALTINSP Dwellings Alternate Materials Inspection B 1R3ALTPLNC Dwellings Alternate Materials Plan Check B 1 PCESS Cesspool P 1PPRSEWG Ea. Private Sewage Disposal System P I PRSEW ER Sewers P 1 BPSPRINK Lawn Sprinkler/Backflow P I BPWSVCS Main Water Service P / 1 1 BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT TYPES 1 BSEISMICRE SeismicResidential B 1RER00FRES Residential Re -roof Each 100 SF B CITY OF CITY OF CUPERTINO ADDITON/REMODEL CUPERTINO FEE SCHEDULE Quantity Sq Ft Fee ID Fee Description Fee Group Permit Type IREMRES2 Remodel Residential Greater than 1000 sq ft B 1 REMRES3 Remodel Residential Greater than 2500 sq ft. B 1REROOFRES Residential Re -roof Each 100 SF B REMODEL PLNCK 1 STPLNCK (1-3 for remodel) Standard Plan Check B NOT FOR OVER THE COUNTER PLAN CKS. WINDOW/SLIDING 1R3SFDREM GLASS DOOR I WINREP Replacement windows (ea 8 windows) B IWINNEWNSTR New Window (non- structural) B IWINMEWSTR New Window (Structural Shear Wall/Masonry) B I WINBAYSTR Bay Window (Structural) B SKYLIGHTS 1R3SFDREM 1 SKYL<l 0 SF Skylight less than 10 sf B 1 SKYL> 10SF Skylight greater than 10 sf or structural B 1STAIRS Stairs -first flight/ea addt'l B --rv-A V 1—>o C_ I EPERMITFEE Electrical Permit Fee E 1 MPERMITFEE Mechanical Permit Fee M 1 PPERMITFEE Plumbing Permit Fee P 1 ELCPLNCK Stand Alone Electric Pln Ck (hourly) E I 13 7__L2 6- OWNER -BUILDER DISCLOSURE FORM 'l :d:;�u,G���11...'V,,.,"r �-w",_�.�r'G, _,=�.=r:"�!,n`��e, : •'=...� 'der `,4:::=!�'�� CILJPEIE�"I�l[�[� 717177-322S =1: ,4:8e —i 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 A _3 / APN 13 OWNER NAME V 'GNA kRl�1—H+1 VIM$ I GI OWNEIIADDRESS_gE2� 3 STOWS 1381 DC�� DESCRIPTION OF WORK: 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 having 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 indicated. An agent of the owner cannot execute this notice unless you, the property owner, obtain the prior approval of the permitting authority. OWNER'S ACKNOWLEDGMENT AND VERIFICATION OF INFORMATION (DIRECTIONS: Please read and initial each statement below to signify you understand or verify this information.) V k 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. 1, 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. NJ �- 2. 1 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. V �_ 3. 1 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. V Y_ 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. V_)(,__5. I 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 hundred dollars ($500), including labor and materials, I may be considered an "employer" under state and federal law. _ � 6. I 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. \JV- 7. 1 understand under California Contractors' State License Law, an Owner -Builder who builds single-family residential structures cannot legally build them with the intent to offer them for sale, unless all work is performed by licensed subcontractors and the number of structures does not exceed four within any calendar year, or all of the work is performed under contract with a licensed general building Contractor. 0- 8. 1 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. Oi4nerBuilderFo7-772_2010.doc revised 04/12/10