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14090170 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10370 PALO VISTA RD CONTRACTOR:NEW WORLD BUILDER PERMIT NO: 14090170 OWNER'S NAME: GERARD PALLIPURAM 1196 BRANDYBOOD WAY DATE ISSUED:09/25/2014 OWNER'S PHONE: 4088880277 SAN JOSE,CA 95121 PHONE NO:(408)472-3692 fi�gg.. LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL COMMERCIAL T INSTALL TEMP POWER License Class Lic.4 ?5-� 0i1� Contractor 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:$650 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:35702051 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 D 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 DAYS 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 �A "� 'V V Date Y 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 the Bay Area Air Quality Management District I performance of the work for which this permit is issued. will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sections 25505,25533,and 25534. p Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agent: 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 indemnify and keep harmless the City of Cupertino against liabilities,judgments, ARCHITECT'S DECLARATION 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 APPLICATIONvi COMN+UNITY DEVELOPMENT DEPARTMEENT• BUILDING DIIAS1011. 10300 T ORRE AVENUE- CUPERTINO, CA 95014-3233 Rv\ (40B) 777-3228-FAX(40R)7777-3333•buildino0),cuos�tino.orq m IsU IUffft INN \f� ❑PLU?a NG []Iu'✓Cr = .4L 7-L;-,-,=C"T ❑I� C�LLAI��OUS PRO Cr ADDRESS c) I f PN 3S. C�2 OSS. CSS O'P1T�lfl• P:-OTS =-}f L�- �1 sT�-rfuDP.. SS I t SaA,l,z •. I Efx CO:v:ACT KILls I PiioT:- I 1Jtn. STPLcr.1 A.DD?F- S urY,ST.ATz, ZIP I EfX ❑ Oat l ❑ OV.*h =n��T� ❑ 03't._—w km,r ❑ CO?c"4COR ❑COA-,TuCTOp,AC-hT ❑ F.P=--m= ❑aNC-3 ❑ DS O?� ❑ z��'I COA?kC-,ot?flr liC 'lv I =1,7) 2I BUS.LIC r COI✓nATZ Nf�� I L-I✓id.IL I FAX STP. c ADDP :5 ^ 9 I .CITY,STATE,ZIP t l 1�C?utBCT/ENGITwRNA1 I LiCr aENUI,'ER I B S.LICR COIvMXY N AN I I F�l✓�k II. I FAX STP,r.-.T ADDP SS I CITY,STATi,ZIP I PHOTS L-SB Or ❑-�or DilPLe3 ❑ MJLTI-FAtdII Y I PROJECT LK WII DLA D ❑ YES I PROJECT IN ❑YES I IS'rn~BLDG ALN ❑ 115 BUiz.DInG: ❑col4ap a". IMB f?.n\—L_--k-rAa ARBA p No FLom zoT ❑>`o B10-M=-I HOME? ❑ No DEsCP.TPTION OF WORK T=-T VALUATION: 3y r,y eima re jel0\1,I Ce l.7 to each Of he fOlIOSi 1g: I&�uhL°prOpee t Ot+ler Or aL I70riud went 770 aCt o 1 i': �'.. 0»ner 5 oef zlf. I _read thm application and the info-nation I have-provided is correct I have read the Description of Work and verity it is acc» ts. I a�*P-'a Eerily va h zl applica'ole local ordinances and state laws relFtLng to building construction. I au-hor�e.representatives or:Cupertino to enter tine above-id--ntLted grope y for -s-pect-ion Dill— s. S i�Uare or:_ppl2C.I .gent: Date: -� d SU LE'-Nf—,ENTTA.L NtORMATION REE—U= CRIMEz�. c MARINE 11 ME ,�s,ares M—FPR1jisc-.pp?0L1.doc revised 06121171 CITY OF CUPERTINO FEE ESTIMATOR—BUILDING DIVISION ADDRESS: 10370 pato vista rd DATE: 09/25/2014 REVIEWED BY: Mendez APN: BP#: *VALUATION: $650 *PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration / Repair PRIMARY SFD Or Duplex PENTAMATION 1 REAP1 USE: PERMIT TYPE: WORK [ipgauemp ower SCOPE w a `is. ;.axt�313 t Ph(nih. 1'luri t'hcef, Elec.Plan Check 0.0 hrs $0.00 i7, ' 1""ri ril Fee: Plumb. 1'errnir?"ez: Elec.Permit Fee: 1EPERMIT C1r r� Vkcff. Chhe i,Plumb 7n.v,=. Li Other Elec.Insp. El hrs $48.00 lk>c,i /is . f'ea Phviih• Iris)). Fee: NOTE: This estimate does not include fees due to other Departments(i.e.Planning,Public Works,Fire,Sanitary Sewer District,School District,etc. . These ees are based on the prelimina information available and are only an estimate. Contact the De t or addn'1 info. FEE ITEMS (Fee Resolution 11-053 Eff. 7/1/13) FEE QTY/FEE MISC ITEMS Plan Check Fee: $0.00 0 amps Electrical Suppl.PC Fee: (j) Reg. 0 OT O,01 hrs $0.00 $48.00 IERT<200 Temporary Power PME Plan Check: $0.00 Permit Fee: $0.00 Suppl. Insp.Fee:Q Reg. Q OT0 0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $48.00 Administrative Fee: IADMIN $45.00 Work Without Permit? 0 Yes (E) No $0.00 Advanced Plannin&Fee: $0.00 Select a Non-Residential E) Travel Documentation Fee: 1TRA VDOC $48.00 Building or Structure 0 i Strong Motion.Fee: IBSEISMICR $0.50 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $1.00 $142.50 $48.00 TO°I�AL FEE: $190.501 ) Revis 08/20/