13050088CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 19020 BARNHART AVE
CONTRACTOR: DALTON CARPET
PERMIT NO: 13050088
COMPANY, INC.
OWNER'S NAME: RAMAMURTHY
2900 LAFAYETTE ST
DATE ISSUED: 05/10/2013
OWNER'S PHONE: 4082522612
SANTA CLARA, CA 95054
16,
PHONE NO: (408) 213-0996
JOB DESCRIPTION: RESIDENTIAL ❑ COMMERCIAL 0
❑ LICENSED CONTRACTOR'S DECLARATION
License Class Lica#
REPLACE/REPAIR TILE IN SHOWER/WATER CLOSET
_
AREA OF
Contractor Date
(E) MASTER BATH -'NO OTHER WORK BEING DONE"
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
Sq. Ft Floor Area:
Valuation: $5500
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
APN Number 37537040.00
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 relating
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 ALLED 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
Issued b Date:
granting of this permit. Additionally, the applicant understands and will comply
with all non -point source regulations Ar the Cupertino Municipal Code, Section
9.18.
RE -ROOFS:
Signature Date: --GZ' -
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.
❑ OWNER -BUILDER DECLARATION
Signature of Applicant: Date:
I hereby affirm that I am exempt from the Contractor's License Law for one of
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)
I, 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. I 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 I 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 I
performance of the work for which this permit is issued.
will maintain compliance with the Cu in o Muni 'pal Code, Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance, as provided for by
the Health & Safety Code, Sections ; 25 d 25534.
Section 3700 of the Labor Code, for the performance of the work for which this
permit is issued.
Owner or authorized agent: Date:—t7 / ''
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, aftermaking this certificate of exemption, I
CONSTRUCTION LENDING AGENCY
become subject to the Worker's Compensation provisions of the Labor Code, I must
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
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
ARCHITECT'S DECLARATION
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
costs, and expenses which may accrue against said City in consequence of the
I understand my plans shall be used as public records.
granting of this permit. Additionally, the applicant understands and will comply
with ail non -point source regulations per the Cupertino Municipal Code, Section
Licensed Professional
9.18.
Signature Date
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(4Q8) 777-3228 • FAX (408) 777-3333- • building(aD-cupertino.org
NEW CONSTRUCTION .
❑ ADDITION
❑ ALTERATION / TI LJ REVISION / DEFERRED
ORIGINAL PERMIT #
PROJECT ADDRESS
APN #
3 D ! /�
OWNER NAME
PHONE —
E-MAIL
STREET ADDRESS
L
CITY, STATE, ZIP
e
FAX
CONTACT NAME
1409)
PHONE
E-MAIL
STREET ADDRESS'.
CITY, STATE, ZIP
FAX
❑ OWNER ❑ OWNER -BUILDER
❑ OWNERAGENT
❑ CONTRACTOR ❑ CONTRACTOR AGENT
ElARCHITECT
❑ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME , A
`
LICENSE NUMBER
FCFNSETYPE
BUS. LIC #
COMPANY NAME
E-MAIL
r
FAX
STREET ADDRESS
`
CITY, STATE, ZIP
AoSe, C4-.
5112
PHONE
ARCHITECr/ENGI .EER NAME
LICENSE NUMBER
BUS. LIC #
COMPANY NAME
E-MAIL
FAX
STREET ADDRESS
CITY, STATE, ZIP
PHONE
DESCRIPTION OF WORK
EXISTING US$ PROPOSED USE CONSTR. TYPE # STORIES
USE TYPE OCC. SQ.FT. VALUATION
EXISTG NEW FLOOR DEMO TOTAL
AREA . AREA AREA NET AREA .
BATHROOM KITCHEN OTHER .
REMODEL AREA REMODELAREA REMODEL AREA
To ECK AREA TOTAL DECK/PORCH AREA GARAGE AREA: LIDETACH
❑ ATTACH
#DwELLI1GUNrrs:' isA'SECONDUNrr []YES SECOND STORY ❑YES
BEINGAbDED? ❑NO ADDITION? ❑NO
TRF -APPLICATION []YES IF YES, PROVIDE COPY OF . IS THE BLDG AN ❑ YES " TOTAL VALUATION:
PLANNING APPL9 ONO PLANNING APPROVAL LETTER EICHLERHOME? []NO
By my signature below, I certify to each of the f Ilowing: I am the property owner or d agent to act on eproperty-owner's behalf. I have read this
application and the information I have provi is orrect. I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating to build' co tru on. gize representatives of Cupertino to enter the above-identifie prope for inspection purposes.
Signature of Applicant/Agent: Date:
SUPPLEMENTAL INFORMATION REQUIRED
New SFD or Multifamily dwellings: Apply for demolition permit for
existing building(s):. Demolition permit is required prior to issuance of building
permit for new building. '
_ Commercial Bldgs: Provide a completed Hazardous Materials Disclosure
form if any Hazardous Materials are being used as part of this project. a
_ Copy of Planning Approval Letter or Meeting with Planning prior to 0
submittal of Building Permit application.
-- oNI�NT
BldgApp 2011.doc revised 06/21/11
CITY OF CUPERTINO
F� 1171171P Ti.CTIMATnR — RITII.11ING DIVISION
imADDRESS:
19020 BARNHART AVE
DATE: 05/10/2013
REVIEWED BY: MELISSA
APN: 375 37 040
BP#:
*VALUATION: 1$5,500
*PERMIT TYPE: Building Permit
PLAN CHECK TYPE: Alteration / Repair
PRIMARY SFD or Du lex
p
0.0 1
PENTAMATION 1GENRES
PERMIT TYPE:
USE:
PME Plan Check:
$0.00
WORK
REPLACE/REPAIR TILE IN SHOWER/WATER CLOSET AREA OF E MASTER BATH**NO OTHER
SCOPE I
WORK BEING DONE**
Llech. Plan Check
-m"ch- Permit Fee:
01her Alech. Insp.
Arleen. Insp. Fee:
Plumb, Plan ('heck
Plumb. Permit Fee:
Other Plumb Insp.
Plumb. Issp. Pee:
Elec. Plan Check
Elec. Permit Fee:
Other Elec. Insp.
Elec. Insp. Fee: u
NOTE: This estimate does not include fees due to other Departments (t.e. rtammng, ruottc wor/cs, tire, Jun/turyJewer utairtuy ounavc
�__- _ - c___a .. .a ........i:....;....,...:.,f:.,. ..t:..a ..,...:/nh/o Dad Orn Dani na octirantn_ rantart the Dent for addn'l info.
FEE ITEMS (Fee Resolution 11-053 E . 7/1/12)
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee: Hourly Only? ® Yes Q No
$0.00
1 hours
$133.00
Plan Check, Hourly
ISTPLNCK
Suppl. PC Fee:_ Q Reg. 0 OT
0.0 1
ht's
$0.00
PME Plan Check:
$0.00
Permit Fee: Hourly Only? ® Yes Q No
$0.00
Suppl. Insp. Fee -(F) Reg. 0 OT0,0
hrs
$0.00
PME Unit Fee:
$0.00
PME Permit Fee:
$0.00
Construction :Ta .-
Adininistrative Feer
E)
Work Without Permit? 0 Yes (E) No
$0.00
Advanced Planning Fee:
$0.00
Select a Non -Residential
Building or Structure
I i
Travel Docurnentalion Fees:
Strong Motion Fee: IBSEISMICR
$0.55
F 1.0 1 hrs
$133.00
Inspections
ISTINSP Inspection, Hourly
Bldg Stds Commission Fee: 1BCBSC
$1.00
�° ��
;
$1.55
$266.00_.
pow-
$267.55
�N Revised: 04/29/2013