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12030112 REV1 ""ILA RGION CITY OF CUPERTINO BUILDING PERMIT. _( Z- 12- BUILDING ZBUILDING ADDRESS: 22487 PALM AVE CONTRACTOR:AB CONSTRUCTION AND PERMIT NO:12030112 REMODELING INC OWNER'S NAME: SUMAN CHERUKURI 1360 LOCUST ST DATE ISSUED:03/22/2012 OWNER'S PHONE: 6502786254 SAN JOSE,CA 95110 PHONE NO:(408)597-5490 ❑ LICENSED CONTRACTOR'S DECLARATION � F' BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class Lic.# MECH RESIDENTIAL COMMERCIAL Contractor Date - I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:INSTALLATION OF LEVITON PRE-WIRE SYSTEM FOR (commencing with Section 7000)of Division 3 of the Business&Professions RESIDENTIAL ELECTRICAL VEHICAL CHARGING STATION IN Code and that my license is in full force and effect. GARAGE 4/5-REVISION#I-CHANGE ENGINEER OF RECORD AND REVISE LATERAL DESIGN4/12/2012 REV#1 ISS'D 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. Sq.Ft Floor Area: Valuation:$600 APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is APN Number:35703071.00 Occupancy Type: 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, PERMIT EXPIRES IF WORK IS NOT STARTED costs,and expenses which may accrue against said City in consequence of the granting of this permit. Additionally,the applicant understands and will comply WITHIN 180 DAYS OF PERMIT ISSUANCE OR with all non-point source regulations per the Cupertino Municipal Code,Section 180 DAYS FROM LAST CALLED INSPECTION. 9.18. Signature Date Issued by: �� ,��TG�1 Date: Y./C? ❑ OWNER-BUILDER DECLARATION' I hereby affirm that I am exempt from the Contractor's License Law for one of RE-ROOFS: the following two reasons: All roofs shall be inspected prior to any roofing material being installed.If a roof is 1,as owner of the property,or my employees with wages as their sole compensation, installed without first obtaining an inspection,I agree to remove all new materials for will do the work,and the structure is not intended or offered for sale(Sec.7044, inspection. Business&Professions Code) I,as owner of the property,am exclusively contracting with licensed contractors to Signature of Applicant: Date: construct the project(Sec.7044,Business&Professions Code). I hereby affirm under penalty of perjury one of the following three ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER declarations: I have and will maintain a Certificate of Consent to self-insure for Worker's HAZARDOUS MATERIALS DISCLOSURE 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 read the hazardous materials requirements under Chapter 6.95 of the California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain I have and will maintain Worker's Compensation Insurance,as provided for by compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health& Section 3700 of the Labor Code,for the performance of the work for which this Safety Code,Section 25532(a)should I store or handle hazardous material. permit is issued. Additionally,should I use equipment or devices which emit hazardous air I certify that in the performance of the work for which this permit is issued,I shall contaminants as defined by the Bay Area Air Quality Management District I will not employ any person in any manner so as to become subject to the Worker's maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the Compensation laws of California. If,after making this certificate of exemption,I Health&Safety Code,Sections 25505,25533,and 25534. become subject to the Worker's Compensation provisions of the Labor Code,I must lam' forthwith comply with such provisions or this permit shall be deemed revoked. Owner ora or' en: Date: APPLICANT CERTIFICATION CONSTRUCTION LENDING AGENCY 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 I hereby affirm that there is a construction lending agency for the performance of work's to building construction,and hereby authorize representatives of this city to enter for which this permit is issued(Sec.3097,Civ C.) upon the above mentioned property for inspection purposes.(We).agree to save Lender's Name indemnify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City in consequence of the Lender's Address granting of this permit.Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code,Section ARCHITECT'S DECLARATION 9.18. Nr"_1 I understand my plans shall be used as public records. Signature Dae 1 Licensed Professional CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 REVISION (408)T773228-FAX(408)TT7-3333-building(cDcuperdno.org �r CUPERTINO ❑NEW'CONSTRUCTION [I ADDITION ALTERATION/TI ❑ REVISION/DEFER M ORIGINAL PERMIT i# 'Z l/-�7 L PROTECT ADDRESS APN# s7 - 03 . 7 OWNERNAME5'u ^ PHO NE D :ZE-MAILoAAAJ &k STREET ADDRESS 2� �C(f QTY.SPATE.ZIP F�I.G'C 44- CONTACT NAME PRONE E-MAIL SIREETADDRESS CITY,STATE,ZIP FAX i ❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCEITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT CONTRACTOR NAME LICENSE NUMBER 7LICENSETTFE BUS.LIC# COMPANY NAME E-MAIL FAX STREET ADDRESS CTIY.STATE,21P PHONE AR GINEER NAM LICENSE NUMBER BUS.UC# 33 CQMPANY E- F $71 72A STREET ADDRE d _ e� CITY.STATE,ZIP PH �J 1 DESCRIFIION OF WORK RD EXISTING USE PROPOSED USECONSTR.TYPE #STORIES USE TYPE OCG SQ Fl. VALUATION(S) �r1 P73 EXISl'G NEWFLOOR DEMO TOTAL AREA AREA AREA NET AREA BATHROOM KITCHEN OTHER REMODELAREA REMODELAREA REMODELAREA PORCH AREA DECK AREA TOTAL DECKTPORCH AREA I GARAGE AREA DETACH ❑ATTACH #DWELLING UNITS: LSA SECOND U Tr []YES SECOND STORY []YES BEING ADDED? ONO ADDTTYON? []NO PRE-APPLICATION ❑YES IF=PROVIDE COPY OF IS TBE BLDG AN ❑YEs RECIIyED BY- TOTAL VALUATION: PLANNING APPL# ❑NO PLANNING APPROVAL LETTER EICBLER SOME? ❑NO E� / By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on the prMp erty.owner's behaTf.I have read this application and the infounatioa I have provided is correct 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 I authorize representatives of Cupertino to enter the above-57d property far inspection purposes. Signature of Applicant/Ageat Dom; [ � SUPPLEMENTAL INFORMATION QUAKED PLAN CHECK TYPE ROOTING SLIP New SFD or Multif oily dwellings: Apply for demolition permit for ❑ oy�-tom comvT>;i:R ❑ atzrDarGPLANIM'VMW existing building(s). Demolition permit is required prior to issuance of building permit for new building. ❑ EXPRESS ❑ PLANMGPLANREVIEW Commercial Bldgs: Provide a completed Hazardous Materials DisclosureSTANDARD ElPUSLICWORISS Tor-m- if any Hazardous Materials are being'used as part of this project ❑ LARGE ❑ ME WEPT _Copy of Planning Approval Letter or Meeting with Planning prior to ❑ n�Aaox ❑ S, Agy swat DISTRICT submittal of Building Permit application. ❑ M"MONI NM TAL HEALTH. Bldgdpp Z011.doc revised 06/21/11 CITY OF CUPERTINO FEE ESTIMATOR-BUILDING DIVISION ADDRESS: 22487.Palm Ave DATE: 04/05/2012 REVIEWED BY: Sean APN: 357-03-071 BP#: 'VALUATION: Iso *PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration/ Repair PRIMARY SFD or Duplex PENTAMATION 1GENRES USE: PERMIT TYPE: WORK HRevxision#1:,Change-Engineer of Record and revise structural design to eliminate interior shearwalls SCOPE sting portion of residence. h aµ Ltech.Plan Check Plumb,Plan Check Elec.Plan Chcek L1i>clt.Pcertnit Free: Plumb.Permit Fee: Elec. Permit l''ce: Other;llec•h. lnsp- Other Plumb Insp. Cather Elec.Insp. Aaech. Insp. Fe,': Plumb. hrslr.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). Thesefees are,based on the"relimina information available and are only an estimate Contact the Dept for addn 11 info. FEE ITEMS (Fee Resolution 11-053 E . 7111111 FEE QTY/FEE MISC ITEMS Plan Check Fee: Hourly Only? Q Yes (j) No $0.00 0 hours Plan Check,Hourly Suppl. PC Fee: (j) Reg Q.OT 0.0 hrs $0.00 $130.00 ISTPLNCK PME Plan Check: $0.00 Permit Fee: $0.00 Suppl. Insp. Fee-0 Reg. ®OT0 0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 Censmuction Tax: T-T ative.Pee: Work Without Permit? 0 Yes No $0.00 Advanced Planning Fee: $0.00 Select a Non-Residential Q Building or Structure Tr(ly�l Documentation Fees: � Strong Motion Fee: $0.00 0.5 hrs Change Contractor/Arch Info Blda Stds Commission Fee: $0.00 . $41.00 1ADMIN ¢" $0.00 $171.00 4EE: $171.00 Revised: 1/19/2012