13050162 (2) I
CITY OF CUPERTING BUILDING LDING PE
RM
IT
BUILDING ADDRESS 1015 NOVEMBERIDR CONTRACTOR:T59—+98E PERMIT NO:13050162
OWNER'S NAME: MALLIKARJUN M.URAG fn ICY DATE ISSUED:05/22/2013
OWNERS PHONE;`40$2504754 4,;-,t;��S PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL COMMERCIAL[]
License Class L c.# �,2' a 57K5 WATER HEATER REPLACEMENT&ADD GAS LINE IN
KITCHEN
Contractoli&IC97"/`a^ 1,4—q Date /J--,�Z 2 ✓L
I hereby affirm that 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 3.700 of the Labor Code,for the
performance of the.work for which this permit is issued: Sq.Ft Floor Area: Valuation:$900
I have and will maintain Worker's Compensation Insurance,as provided for by
Section 3700 of the Labor Code,;for the performance of the work for which this APN Number:36213053.00 Occupancy Type:
permit is issued.
APPLICANT CERTIFICATION
I certify that I have read.this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED
correct.I agree to comply with all city and county,ordinances and state laws relating WITIIIN 180 DAYS OF PERMIT ISSUANCE OR
to building;construction,and hereby authorize representatives of this city to enter
upon the above mentioned property!forimspection purposes. (We)agree to save 180 D S OM LAST CALLED INSPECTION
indemnify and keep harmless the city of Cupertino against liabilities,judgments,
costs and;expegseswh�cir may accrue against'said C . in consequence of the Issued b Date '
granting df this perir►rt! Additionally,the appli understands and will comply y'
with all anon-point source's tions per pertino Municipal Code,Section
9 1$ RE-ROOFS:
Signature' Date �DU All roofs shall be inspected prior to any roofing material being installed.If a roof is `
installed without fust obtaining an inspection,I agree to remove all new materials for
inspection.
❑ OWNER-BUILDERDECLARATION
I! Signature of Applicant: Date:
I hereby affirm thatI am exempt from the Contractor's License Law for one of
the following twq reasons., I 1 I1! ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
1,as owner of the prpert ,'or my employes with wages as their sole compensation,
will do!the woik,Iand the structureis,not intended'or offered for sale(Sec.7044,
Business,&Professions Code)
1,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: I Health&Safety Code,Section 25532(a)should I store or handle hazardous
1 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€or':whreh this permit!is issued. ; will maintain compliance with the Cupertino unicipal Code,Chapter 9.12 and
I have and will in*tarn Workers Cpmpensation Insurance,as provided for by the Health&Safety Code,Sections 2 33,an 25534.
Section 3700 of the'Labor'Code,Ifor the performance of the work for which this V 2
Owner or authorized agent: Date;-O-�
permit is issued.
I certify that in the!performance of the work for which this permit is issued,I shall
not employ any personin any manner so.as to become subject to the Worker's CONSTRUCTION LENDING AGENCY
Compensation laws of Califomia. If,aNr!making this certificate of exemption,I
become!subject to the Worker's Cgmpensation,provisions of the Labor Code,I must 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.
forthwithcomply'with such provisions or this permit shall be deemed revoked. p ( )
Lender's Name
j �PPLICANT'CERTIFICATION Lender's Address
I certify that I have read this.application and'state that the above information is
correct 11 agree to comply with all city and'county ordinances and state laws relating
to building constructron,,Md hergby authorize representatives of this city to enter
upone,above men,t, 'property foF,mspect on purposes.(We)agree to save ,
ti} . ARCHITECTS DECLARATION
inderrtnify and kcepl b ess the Crty;of Cupeitino against liabilities,judgments,
costs,a e�Cpe�useslyvhrclp may accrue agamst said City in consequence of the I understand my plans shall be used as public records.
granting otthis pe hi A ditio I T I the applicant understands and will comply
with all non point s u e regulatronsl Qer the Cupertino Municipal Code,Section Licensed Professional
I I
I I
Srgu a bate
!
GENERAL PERMIT APPLICATION MEP
Lo COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 1 U9
10300 TORRE AVENUE•CUPERTINO,CA 95014-3255 . p d
(408)777-3228•FAX(408)777-3333•building(d)-cugertino.ora �� MISC
CUPERTINO
UMBING []MECHANICAL ❑ELECTRICAL ❑MISCELLANEOUS
PROJECT ADDRESS O f
A_ APN# 3 0,
O Z
/WOOWNER NAME Y c /��Oa f PHO ^ E-MAIL
STREET ADDRESS K /C A CITY,STATE,ZIP OC v FAX
CONTACT NAME PHONE E-MAIL
STREET ADDRESS CITY,STATE,ZIP FAX
❑ OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑.ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRAN E L _`! LICENS LICENSETAPE/ BUS.LIC#
COMPANY NAVE' _ ler D � , lI/ � E-MAIL C� FAX
STREET ADDRESS/Le /'V/ CITY,STATE,ZIP PHONE
ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC#
COMPANY NAME E-MAII. FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OFSID or DUPLEX ❑ MULTI-FAMILY PROJECT IN WIIALAND ❑ YES PROJECT IN ❑ YES IS THE BLDG AN El YES
BUILDING: ❑COMMERCIAL URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑NO EICHLER HOME? El No
DESCRIPTION OF WORK
�`y le-Q jt taeeelreA a'j,1 pr's GtI 06M 7�
TOTAL VALUATION: RECEIVE B
cJ �
By my signature below,I certify to each of the following: I am the property o�or authorized agent to act tl property owner's ha I read this
application and the information I have provi is correct. I bave r e escription of Work and verify it is ac urate. I agree to com with 1 applicable local
ordinances and state laws relating to build' tru orize representatives of Cupertino to enter the above-identified property for inspection purposes.
Signature of Applicant/Agent: Date: ✓> .���✓
SUPPLEME AL INFORMATION REQUIRED OFFI SE ONLY
W OVER-THE-COUNTER
❑ EXPRESS
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❑ STANDARD
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❑ MAJOR
MEPMiscApp_2011.doe revised 06/21/11
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 Du lex PENTAMATION PRWHEATR
USE; p PERMIT TYPE:
WORK WATER HEATER REPLACEMENT&ADD GAS LINE IN KITCHEN
SCOPE
s
klech.:Plan Check.. Plumb,Plan Check 0.0 hrs $0.00 Elec.Plan Check
tech.Perrnit Feer Plumb.Permit Fee: 1PPERAHT Elec.Permit Fee:
F)th,� Mech.Insp: Other Plumb Insp. 0.0 hrs $45.00 Other Elee.Insp. LJ
.Insp.Fee: Plurrrh. Insp.Fee: Elec.Insp.Fee:
NOTE:This estimate does not include fees due to other Departments(i.e.Planning,Public Works,Fire,Sanitary Sewer District,School
District,eta). Theseees are based on the prelimina information available and are only an estimate. Contact the Dept-for addn'l info,
FEE ITEMS (Fee Resolution 11-053 E . 7/1/12) FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 = # Plumbing
Suppl.PC Fee: Reg. 60T FO.0 hrs $0.00 $27.00 IPRWHEATR Water Heater
PME Plan Check: $0.00 F-T-1 # Plumbing
Permit Fee: $0.00 $67.00 IPGASRES Piping,Gas<=4 Outlets
Suppl. Insp.Fee-0 Reg. ®OT 0,0 hrs $0.00
PME.Unit Fee: . $0.00
PME Permit Fee: $45.00.
(onstrztction 1 crx:
Administrative Fee: IADMIN $42.00
Work Without Permit? ®Yes (j) No $0.00
Advanced Planning Fee: $0.00 Select a Non-Residential
Travel Documentation Fee: 1TRAVDoC $45.00
Building or Structure
Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item
Bldg Stds Commission Fee:'' IBCBSC $1.00
$133.50 $94.00 $227.50
Revised: 04/29/2013