13090055 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10415 N BLANEY AVE CONTRACTOR:COUNSIL PLUMBING PERMIT NO:13090055
OWNER'S NAME: SURESH BABU CHANNALATH 1127 SOMERSET DR DATE ISSUED:09/10/2013
OWNER'S PHONE: 6506336282 SAN JOSE,CA 95132 PHONE NO:(408)272-2272
❑ /LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL El COMMERCIAL
License Class 3Lf Li..# !J� INSTALL A DEDICATED GAS LINE FROM METER TO
COOK
Contractor iJS 11 Date d RANGE
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. Sq.Ft Floor Area: Valuation:$800
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:31633114.00 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 DA F OM LAST CALLED 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
granting of this permit. Additionally,the applicant understands and will comply Issued by: Date:
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18.
RE-ROOFS:
Signature O)X6" ' Date 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 t eBay Area Air uality Management District I
performance of the work for which this permit is issued. will maintain compliance wi t e Cupertino M icipal C e,Chapter 9.12 d
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code, ns 505,2553 , nd 2553M.
Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agent hAl Date:
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 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 all non-point source regulations per the Cupertino Municipal Code,Section Licensed Professional
9.18.
Signature Date
GENERAL PERMIT APPLICATION
MEP
U12 COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300*ORRE AVENUE•CUPERTINO, CA 95014-3255 {�
(408)717-3228•FAX(408)777-3333•buildinga-cupertino.org V� misc
GUPERTINO I
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PROJECT ADDRESS I b q I-V) �) a APN# Q 22 f
OWNERNAME 5,,Lr
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STREET ADDRESS f0 l CITY,STATE,ZIP FAX--------
CONTACT NAME / PHONE E-MAIL
STREET ADDRESS CITY,STATE,ZIP FAX
❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT XCONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT
CONTRACTOR NAME LICENSE NUMBER LICENS TYPE BUS.LIC#
COMPANY NAME f� ' I ft )1 E-M I /� FAX J/�G_,� p
STREET ADDRESS//,?7 I �� CITY, TE,ZIP �y /1, / PHO
ARCHTTECTXNGINEER 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 FEICHLER
THE BLDG AN ❑YES
BUILDING. ❑COMMERCIAL URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑NO HOME? ❑NO
DESCRIPTION OF WORK n Utq a- ,' /J
TOTALVALUATION:
By my signature below,I certify to each f the following: I am the p rty owner or I)f
ized agent to ac on t property owner's behalf. I have read this
application and the information av p ovided is correct I have r d e Descriptionrk and verify it is at . I agr to comply with all applicable local
ordinances and state laws relay g to ding nstruction. I auth rize epresen 'vesertino to enter the a/bo�ve Wentif d property for inspection purposes.
Signature of Applicant/Agent: Date: �'v d10
SUPPLEMENTAL INFORMATION REQUIRED p P
a
MEPMiscApp_2011.doc revised 06/21/11
CITY OF CUPERTINO
FEE ESTIMATOR—BUILDING DIVISION
ADDRESS: 10415 N Blaney DATE: 09/10/2013 REVIEWED BY: Mendez
APN: BP#: "VALUATION: $800
*PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration/ Repair
PRIMARY SFD or Duplex PENTAMATION 1 RPGAS
USE: PERMIT TYPE:
WORK [t§!Pja dedicated gas line from meter to cook range
SCOPE
Sr
ME
r"re,
,Vkch. Plan Check Plumb.Plan Check 0.0 hrs $0.00 F'1ec..Plan("heck
iLlech.Penult Fee: Plumb.Permit Fee: IPPERMIT Dec. Permit Fee:
Other Afech,Insp. Other Plumb Insp. 0.0 hrs $47.00 Other Elec.Imp.
:Tech.Insp.Fe 1: Plumb. 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,etc). Theseees are based on the mina information available and are only an estimate Contact the De t or addn'l info.
FEE ITEMS(Fee Resolution 11-053 E . 7/1/12) FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 F T-1 # Plumbing
Suppl.PC Fee: (F) Reg. ® OT0.0 hrs $0.00 $70.00 IPGASRES Piping,Gas<=4 Outlets
PME Plan Check: $0.00
Permit Fee: $0.00
Suppl. Insp.Feer Reg. ® OT 0,0 hrs $0.00
PME Unit Fee: $0.00
PME Permit Fee: $47.00
C'onsiruction .Tax:
Administrative Fee: IAD1►11N $44.00
Work Without Permit? ®Yes (E) No $0.00 E)
Advanced Planning Fee: $0.00 Select a Non-Residential (F)
Travel Documentation Fee: ITRAVDOC $47.00 Building or Structure
i
Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC 1 $1.00
$139.50 $ . M' $209.50
� q 70 M
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Revised: 07/01/2013
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