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14050097CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 21867 SHATTUCK DR CONTRACTOR: AG CONSTRUCTION & PERMIT NO: 14050097 REMODELING OWNER'S NAME: SREEKUMAR PARMESWARAN & BEENA DAS 5292 AMELIA DR DATE ISSUED: 05/15/2014 OWNER'S PHONE: 4087250843 SAN JOSE, CA 95118 PHONE NO: (408) 838 -2872 DECLARATION JOB DESCRIPTION: RESIDENTIAL COMMERCIAL LICENSED CONTRACTOR'S REMODEL (E) MASTER & HALL BATHS (106 S.F.) Q 9 \ r License Class_ Lic. # (S J 1 � -'�` tR Contractor v4J:lhspyi 2-01LA 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 Valuation: $12000 p rformance of the work for which this permit is issued. Sq. Ft Floor Area: h ve and will maintain Worker's Compensation Insurance, as provided for by Sec ion 3700 of the Labor Code, for the performance of the work for which this APN Number: 35614003 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 180 DAYS ST CAL SPECTION. upon the above mentioned property for inspection purposes. (We) agree to save indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs, and expenses which may accrue against said City in consequence of the te: granting of this permit. Additionally, the applicant understands and will compl with all non -point source regulations per the Cupertino Municipal Code, n 918. ,,, RE- ROOFS: Date `Z 0 �4 All roofs shall be inspected prior to any roofing material being installed. If a roof is Signature installed without first obtaining an inspection, I agree to remove all new materials for inspection. ❑ OWNER- BUILDER DECLARATION Date: Signature of Applicant: 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, do the work, and the structure is not intended or offered for sale (Sec.7044, will Business & Professions Code) HAZARDOUS MATERIALS DISCLOSURE 1, as owner of the property, am exclusively contracting with licensed contractors to 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 Code, Section 25532(a) should I store or handle hazardous declarations: Health & Safety 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 the Cupertino Municipal Code, Chapter 9.12 and performance of the work for which this permit is issued. will maintain compliance with Health & Safety ty 25533, and 25534. the Code, Sections 25505, I have and will maintain Worker's Compensation Insurance, as provided for by �p Section 3700 of the Labor Code, for the performance of the work for which this Owner or authorized agent: �►-� Dater 'f 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 CONSTRUCTION LENDING AGENCY Compensation laws of California. If, after making this certificate of exemption, I I hereby affirm that there is a construction lending agency for the performance of become subject to the Worker's Compensation provisions of the Labor Code, I must work's for which this permit is issued (Sec. 3097, Civ C.) forthwith comply with such provisions or this permit shall be deemed revoked. 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 CUPERTINO CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014 -3255 (408) 777 -3228 • FAX (408) 777 -3333 • build ing(c7cupertino.org ❑ NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION / TI ❑ REVISION / DEFERRED ORIGINAL PERMIT # PROJECT ADDRESS 1 6 S" X�,� LR � APN # �J / 1 .I D 3 OWNER NAME PHON �% C:� E -MAAIL STREET ADDRESS _ �p Z- (c, S CITY, ST ZIP FAX 1 `t T�-f �1c 'CL F— � O CONTACT NAME J� PHONE -MAIL STREET ADDRESS t^2Q 2 A , n �T 7" CITY = Z FAX ❑t"OWWNER AGENT XONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT ❑ OWNER ❑ OWNER - BUILDER CONTRACTOR NAME J LICENSE NUMBER LICENSE TYPE BUS. LIC # COMPANY NAM n — d���CQ E -MAIL FAX STREET ADDRES5�2 2 Cr� �ZI MNF � S � � 5 ARCHITECT/ENGrNEER NAME LICENSE NUMBER BUS. LIC # COMPANY NAME E -MAIL FAX STREET ADDRESS CITY, STATE, ZIP PjjopE i DESCRIPTION OF WORK _ Z Qom-© SS i O EXISTING USE 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 i C 1 REMODEL AREA REMODEL AREA PORCH AREA DECK AREA TOTAL DECK/PORCH AREA GARAGE AREA: FIDETACH ❑ ATTACH I # DWELLING UNITS: IS A SECOND UNIT ❑ YES SECOND STORY ❑ YES BEING ADDED? ONO ADDITION? ❑NO PRE = APPLICATION OYES IF YES, PROVIDE COPY OF IS THE BLDG AN ❑YES IUSD`B'y }` . is"' TOTAL VALUATION: PLANNING APPL # ❑ NO PLANNING APPROVAL LETTER EICHLER HOME? ❑ NO #..�_ fLAC-AZ) By my signature below, I certify to each of the following: I am the r owne ri agent to ac the prope er's behalf. I have read this application and the information I have provided is correct. I have read the Descrip�of rk an v ree to com ly with all applicable local ordinances and state laws relating to building construction. I authorize a resentatipertino to e ov e- identified property for inspection 6urposes. y Signature of Applicant/Agent: Date: < SUPPLEMENT ORMATION REQUIREDNo -.� OVER,COUiVTER �'�� BUDIrIL EW GPLANREY` I fin,> blew SFD or Multifamily dwellings: Apply for demolition permit for existing Demolition permit is rior to issuance of building building(s). b permit for new building. P RSSa lz k i:b y "sa " �PYAGPLAN� EW Commercial Bldgs: Provide a completed Hazardous Materials Disclosure PUBLIC WORKS - a ' _ form if an Hazardous Materials are being used as art of this project. Y g P P J wq .` cy xr i X .'ate '. p '4 ^�''•3 S A is- -aT� -t , x i C Copy of Planning Approval Letter or Meeting with Planning prior to _ submittal of Building Permit application. JQ P ����� © SAAITAi2YSEWERDISTRICT BldgApp_201 1. doc revised 06/21/11 �.� CITY OF CUPERTINO rT n T, OrFITA/F A Wd1101 I 'FTT7 T1TNr_' DFVTCT(l1V 11I wd). Plan Ph n Cn.v F'ee. , Permit Pee 1 z (}r1r�r :llecle. fn, 01/ler Plumb Jaq). / sec. Insp, llharah. Trsp. T(le: lec- Imp _u�_ 01__.6_. L•:.. _. 0,.... s...... Q,....n.. Tl.ct.int .Qrhnn/ NOTE: This estimate does not inctuaefees aue to otnervepartmena (i.e. raura.ta.e5, .��• •• �• ^�� - �• �• - - -- - • _. _ ____ ___, _ __ _ I _ -.- . / . s . t th , lloni Fnr nddn'1 iNin_ ,uistrtct, eta ). lnese fees are nttsea un the pic ca..usu. FEE ITEMS (Fee Resolution 11 -053 E . 7ff /1/13) 21867 SHATTUCK DR DATE: 05/15/2014 REVIEWED BY: MELISSA liaADDRESS: APN: 35614 003 BP #: *VALUATION: $12,000 xPERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration / Repair PRIMARY SFD or Duplex PME Plan Check: PENTAMATION 1 R3SFDREM PERMIT TYPE: USE: Permit Fee: $0.00 Suppl. Insp. Fee-.(F) Reg. 0 OT WORK REMODEL E MASTER & HALL BATHS 106 S.F. $0.00 PME Unit Fee: $0.00 SCOPE $0.00 11I wd). Plan Ph n Cn.v F'ee. , Permit Pee 1 z (}r1r�r :llecle. fn, 01/ler Plumb Jaq). / sec. Insp, llharah. Trsp. T(le: lec- Imp _u�_ 01__.6_. L•:.. _. 0,.... s...... Q,....n.. Tl.ct.int .Qrhnn/ NOTE: This estimate does not inctuaefees aue to otnervepartmena (i.e. raura.ta.e5, .��• •• �• ^�� - �• �• - - -- - • _. _ ____ ___, _ __ _ I _ -.- . / . s . t th , lloni Fnr nddn'1 iNin_ ,uistrtct, eta ). lnese fees are nttsea un the pic ca..usu. FEE ITEMS (Fee Resolution 11 -053 E . 7ff /1/13) ......& ..•w..K.,... FEE --•_ -- -. _ QTY/FEE ____ ___ ______ MISC ITEMS Plan Check Fee: $0.00 = S.f. Remodel, Bath (< =300 sf) $626.00 IREMRESBAT Suppl. PC Fee: (F) Reg. 0 OT 0.0 I hrs $0.00 PME Plan Check: $0.00 Permit Fee: $0.00 Suppl. Insp. Fee-.(F) Reg. 0 OT 0.0 1 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 :(rjlYtll7tt.fYdiiL'G' �'c'[': Work Without Permit? 0 Yes Q) No $0.00 Advanced Planning Fee: $0.00 Select a Non - Residential G Building or Structure 7 r w;,,al 0occrrm enfuiiori Tees_ Strong- Motion Fee: 1BSEISMICR $1.20 Select an Administrative Item BIdy, Stds Commission Fee: IBCBSC $1.00 5 BLS` $2.20 $626.00 TOTAL FEE: $ 628.20 rcevisea: u4ru u/-u ,-+ CUPERTINO CONTRACTOR / SUBCONTRACTOR LIST Building Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014 -3255 Telephone: 408- 777 -3228 Fax: 408-777-3333 JOB ADDRESS: -Z 1 $ Cam' -e �Tt C �� PERMIT # OSO OWNER'S NAME: PHONE # 0 83S Z$Z GENERAL CONTRACTOR. r;--4.)3 N . �ZAS 5 _ BUSINESS LICENSE # ADDRESS: Sz 2 -btz CITY /ZIPCODE: 1:3Sii *Our municipal code requires all businesses working in the city to have a City of Cupertino business lieense. NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE GENERAL CONTRACTOR AND ALL SUBCONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE. I am not using any subcontractors: Signature Date Please check applicable subcontractors and complete the following information: Owner / 0JV1&actor Signature ate SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets & Millwork Cement Finishing Electrical Excavation Fencing Flooring / Carpeting Linoleum / Wood Glass / Glazing Heating Insulation Landscaping Lathing Masonry Painting / Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile Owner / 0JV1&actor Signature ate ft:rf- 5-7t-� 4AL-4 Rprws clu��vif�l)�u Vol MAS Tr -R (3A-mupom O REC EIVED MAY 15 2014 13Y 7b O jc ti Th C VD BY , li>- F-S �e V/e Wed NC& MU3��ELORME BUILDING DIVISION - APP set �andspe avor O'P'm site during cons ruction. It is changes or alterations on sa stamping of this plan and PERMIT'NO. UST be kept at the awful to make any or to deviate Building Official. tj-ns S!--j4,-,. I N10,T ral of �\ y(/// VO �. dry Cp VU ift• 5v \l,1. Building Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014 -3255 Telephone: 408 - 777 -3228 C U P E RT I N O Fax: 408- 777 -3333 CONTRACTOR/ SUBCONTRACTOR LIST JOB ADDRESS: 2 j Z� C-� �'c-e A T U C -L�- PERMIT # OWNER'S NAME: X52 . its s. e k V— PHONE # GENERAL CONTRACTOR iE_)J,%A kt::i fi=r ms BUSINESS. LICENSE # ADDRESS: z 2 _ }=Q CITY /ZIPCODD: �,� ' c ��5 1t *Our municipal code requires all businesses working in the city to have a City, of 1Cgpgrtino business license. NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTIONS) WILD BE SCHEDULED UNTIL THE GENERAL CONTRACTOR AND ALL SUBCONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE. � ��� I am not using any subcontractors: �� Signature Date Please check applicable subcontractors and complete the following information: SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets & Millwork Cement Finishing Electrical Excavation Fencing Flooring / Carpeting Linoleum / Wood Glass / Glazing Heating Insulation Landscaping Lathing - Masonry Painting / Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile Owner / 44 1 Signature Date