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13050162 li I . CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 1015 NOVEMBER DR CONTRACTOR:T49—T6iW s PERMIT NO:13050162 OWNER'S NAME:'MALLMARJUN MURAG .� DATE ISSUED:05/22/2013 OWNER'S PHONE;•4082504754 F 4/1 k;,tn PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL LJ COMMERCIALO 3 �P Lic.`#" a' ��tS�" WATER HEATER REPLACEMENT&ADD GAS LINE IN License Class // W/ " �( 0,;. KITCHEN Contractor�/� � Date I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with,Section 7000).of Division 3of 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. Sq.Ft Floor Area: Valuation:$900 I have and will maintain Worker's Compensation Insurance,as provided for by Section 3700 of the Labor Code,for the performance of the work for which this APN Number:36213053.00 Occupancy Type: permit is issued. APPLICANT CERTIFICATION I certify.that I have readthis application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED correct,,,I agree.to comply with all city.and county;ordinances and state laws relating WITHIN 180 DAYS OF PERMIT ISSUANCE OR to budding construction,and hereby authorize representatives of this city to enter upon the:above metitioned property foz inspection purposes. (We)agree to save 180gDSOM LAST CALLED INSPECTION indemnify'and keep harmless the City of Cupertino against liabilities,judgments, costs and;expenses jwhicii;may accrue against said C' in consequence of the Issued by Dater ' granting:of flus permit,i I Additionally,the i pli understands and will comply withall anon-point source'r tions'per pertino Municipal Code,Section 9.1$ ROOFS: Signatttre' � i � '� ' Date GY All roofs shall be inspected prior to anyy roofing material being installed.If a roof is installed without first obtaining an inspection,I agree to remove all new materials for inspection. ❑ i� I'. OWNER- UILDERDECLARATION' ! Signature of Applicant:. Date: I hereby.affirm that)t am exempt from the Contractor's License Law for one of the following two reasons:!: !' D' 11 1 i ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER I,as owner of the prppert ,or my employbes with wages as their sole compensation, will doithe work,iand the structure isnot 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(Se0044,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: j !. 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 emifhazardous 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 whie this permit is issued. will maintain compliance with the Cupertiu unicipal Code,Chapter 9.1Z and I have and will main i� YVorkerjs Cpmpensat1. ion Insurance,as provided for by the Health&Safety Code,Sections 2 33,an 25534. Section 3700 of the Labor'Code for the performance of the work for which this i Owner or authorized agent: Date: � 2 permit is issued. : I certify that in the'performance of the work for which this permit is issued,I shall not employ any person ini any manner so as to become subject to the Worker's CONSTRUCTION LENDING AGENCY Compensation lawslof California If,after•making this certificate of exemption,I become;subject to the Workers Compensation,provisions of the Labor Code,I must I hereby affirm that there is a construction lending agency for the performance of 1 ' I� 11' • work's for which this permit is issued(Sec.3097,Civ C.) forthwithlcomply(with such,provl srot►s or,this permit shall be deemed revoked. Lender's Name r�PPLICANT CERTIFICATION Lender's Address I certifx that I have read this application and state that the above information is correct/ 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 uportttieabove mcntigpe ,'grope{tyllor,rpspectFon'purposes.(We)agree to save ARCHITECT'S DECLARATION index n#y-andikeepl h�rni ess the City,of Cupertino against liabilities,judgments, cons', :expcirses iYvhrc�mny accrue against said City in consequence of the I understand my plans shall be used as public records. grantui ,qf thisi perruA�i��ldditionall,�,I the applicant understands and will comply with a npn�pri s�ja ie ul7tionsi ern a Cupertino Municipal Code,Section Licensed Professional I I I' I � • 91 � . . ��I ' ! ,I �i � Date Siguature I I GENERAL PERMIT APPLICATION MEP COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO,CA 95014-3255 . f CUPERTINO (408)777-3228•FAX(408)777-3333•building(a cupertino.org t3�� MISC UMBING ❑MECHANICAL ❑ELECTRICAL / [:1 MISCELLANEOUS PROJEO AD SS APN# CP G 3 05 OWNER NAME /v/�Oa PHO 0� �"' E-MAIL STREET ADDRESS !c /l CITY, STATE,ZIP (,�©y FF CONTACT NAME PHONE E-MAIL STREET ADDRESS CITY,STATE, ZIP FAX ❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT CONTRAC N E � ` _`! 3�LIC ENS 7 / LICE T1� , BUS.LIC# COMPANY N —` E-MAIIb� �C� FAX STREET ADDRESS/Le CITY,STATE,ZIP PHONE ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC# COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE USE OF SFD or DUPLEX ❑ MULTI-FAMILY PROJECT IN WI.DLAND ❑ YES PROJECT IN ❑ YES IS THE BLDG AN ❑ YES BUILDING: ❑COMMERCIAL URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑NO EICHLER HOME? ❑NO DESCRIPTION OF WORK TOTAL VALUATION: RECEIVE B cJ � By my signature below,I certify to each of the following: I am the property oo guthorized agent to act o t property owner's ha . I read this application and the information I have provi is correct. I have r e escnb 'ption of Work and verify it is ac urate. I agree to com with 1 applicable local ordinances and state laws relating to buil ' tru orize representatives of Cupertino to enter the above-identified property for inspection purposes. Signature of Applicant/Agent: Date: ✓s ��.��/� SUPPLEMENtAL INFORMATION REQUIRED OFFiCFrVJSE ONLY �W OVER-THE-COUNTER �" ❑ EXPRESS U x ❑ STANDARD zU a ❑ LARGE P. ❑ MAJOR MEPMiscApp_201 Ldoc revised 06121111 CITY OF CUPERTINO - FEE ESTIMATOR-BUILDING DIVISION ADDRESS: 1015 NOVEMBER DR DATE: 05/22/2013 REVIEWED BY: MENDEZ APN: BP#: *VALUATION: $900 *PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration/Repair PRIMARY SFD or Duplex PENTAMATION PRWHEATR USE: p PERMIT TYPE: WORK WATER HEATER REPLACEMENT&ADD GAS LINE IN KITCHEN SCOPE vfec:h Plan Check.. Plumb.Plan Check 0.0 hrs $0.00 Elec.Plan Check Lli:ch.1'erntit Feer Plumb.Permit Fee: 1PPERMIT Elec.Permit Fee: Othey hlech.Ash: Other Plumb Insp. 0.0 hrs $45.00 Other Elec.Insp. ,t ech.Insp.Fee: Plurnb. Insp.Fee: Elec.Insp..Fee: NOTE:This estimate does not include fees due to other Departments(Le.Planning,Public Works,Fire,Sanitary Sewer District,School District,eta). These fees are based on the prellmina information available and are only an estimate. Contact the De t or addn7 info. FEE ITEMS (Fee Resolution 11-053 E . 7ff 11/12) FEE QTY/FEE MISC ITEMS Plan Check Fee: $0.00 F 1 # Plumbing Suppl.PC Fee (E) Reg. ® OT FO.0 hrs $0.00 $27.00 IPRWHEATR Water Heater PME Plan Check: $0.00 Fi # Plumbing Permit Fee: $0.00 $67.00 IPGASRES Piping,Gas<=4 Outlets Suppl. Insp.Fee1q Reg. ® OT 0,0 hrs $0.00 PME.Unit Fee: . $0.00 PME Permit Fee: $45.00 6)ns rztction :I'ax. Administrative Fee: 1ADMIN $42.00 Work Without Permit? ®Yes (E) No $0.00 Advanced Planning Fee: $0.00 Select a Non-Residential Building or Structure 0 Travel Documentation.Fee 1TRAVDOC $45.00 Strong Motion Fee. IBSEISDIICR $0.50 Select an Administrative Item Bids Std s Commission Fee: 1BCBSC $1.00 $133.50 $94.00 $227.50 Revised: 04/29/2013