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15010156 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 21180 HAZELBROOK DR CONTRACTOR:BATH FITTER PERMIT NO: 15010156 NORTHERN CALIFORNIA OWNER'S NAME: IYYAVOO ARUL AND PRAKASHPATHY DEEPA 2118 ZANKER RD DATE ISSUED:01/27/2015 OWNER'S PHONE: 4082199320 SAN JOSE,CA 95133 PHONE NO:(408)834-1111 ❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL ❑ COMMERCIAL Q�y�r REPLACE SHOWER VALVE License Class G'ro Lic.# /0 rDJ REVISION#2-REVISE FRAMING TO BATHROOM � REMODEL- Contractor /,7/ olr !f�sr,�. Date ZAA4 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 dec I have and will maintain a certificate of consent to self-insure fo Compensation,as provided for by Section 3700 of the Labor Co e performance of the work for which this permit is issued, Sq.Ft Floor Area: Valuation:$8197 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:32655025 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 DAYS FROWLAST CALLED IN SP TION. 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. d ' ally,the applicant understands and will comply Issued by: Date: with all non-point so ions per the Cupertino Municipal Code,Section 9 18. � RE-ROOFS: Signature Dateo/nny/�kr All roofs shall be inspected prior to any roofing material being installed.If a roof is 77''��!! installed without first obtainin i inction,I agree to remove all new materials for inspection. 14 ❑ OWNER-BUILDER DECLARATION _ I hereby affirm that I am exempt from the Contractor's License Law for one of Signature of Applic Dat. the following two reasons: ALL ROOF CC�INGSTO S"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 Municipal Code,Chapter 9.12 and I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sectio 33,and 25534. Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. . Owner or authorized agent: Dat 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 ofexemption,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 CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 CUP1_RTiNO (.4.08).777=3228•,FAX(408)777-3333•buildingacupetno.org ❑NEW CONSTRUCTION •,a ADDITION.,,, ❑ ALTERATIONI TI REVISION/DEFERRED "ORIGINAL PERMIT# PROJECT ADDRESS APN# zz OWNER NAME�n n / PHONE rJ /q E-MAIL STREET ADDRESS CITY-,-STATE,ZIP FAX CONTACT NAME- PHONE E-MAIL STREET ADDRESS` CITY,STATE,;ZIP FAX " ❑ OWNER- ❑ OIAINER-BUILDER"' '❑'OWN'ERAGENT 0 CONTRACTOR CONTRACTOR AGENT - (] ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT CONTRACTOR NAME r7' LICENSE NUMBER LICENSE TYPE BUS.LIC# " COMPANY NAME //� E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE ARCHTTECT/ENGTNEER NAME LICENSE NUMBER BUS.LIC# COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE DESCRIPTION OF WORK 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 REMODEL AREA REMODEL AREA PORCH AREA DECK AREA TOTAL DECK/PORCH AREA I GARAGE AREA: EIDETACH ❑ATTACH #DWELLING UTTTS: IS A SECOND UNIT ❑YES SECOND STORY ❑YES BEING ADDED? ONO ADDITION? ❑NO PRE-APPLICATION ❑YES IF YES,PROVIDE COPY OFIS THE BLDG AN ❑YES2ECEi -ABY a z TOT ALUATION: PLANNING APPL 9 NO PLANNING APPROVAL LETTER EICHLERHOME? NOMORN ` - --- By my signature below,I certify to each o e fol ing: I am the property owner or authorized agent to ac n e property owner's behalf. I have read this application and the information I have d' ect. 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 ction. I authorize representatives of Cupertino to enter the above-identified property for inspection purposes. Signature of Applicant/Agent: Date: 4✓� SUPPLEMENTA IN ORMATION REQUIRED nb P `c> :ciciYrE. _R ncsLlr New SFD or Multifamily dwellings: Apply for demolition permit for r $uuDe PLAT.RE«w existing building(s). Demolition permit is required prior to issuance of building rTlcoimTER a � permit for new building. '�ExPRESS - ' ` P. INGPLAI\tEVIEw NINE _Commercial Bldgs: Provide a completed Hazardous Materials Disclosure sTnAxD�IN � x �'uBLlcyvo�ucs form if any Hazardous Materials are being used as part of this project. " h �� x ` R ` ��T�II�EDEPT _Copy of Planning Approval Letter or Meeting with Planning prior to � lA�QR � ��" �� SA''I�TTARY SEY�'ERDISTRICT submittal of Building Permit application. Fs� B1dg4pp_2011.doc revised 06/21/11 414' 7 T T qq-5 _11�011ire 00) FF1 r -TIN ,UPFP, O j3ujldjng oepartr'npnt FEB 262015 PLIANCE e4e Reviewed BY. d/-c &Y�c c, n4 yl IV r 611pa Lblmw� A4EtqT PA CUPER.'ri EMT--- N. N APppzo "m r ,' 7h:- VED 4� Gil P"!�ns C-;�d sppc�- job site d"'.. ;f. icati ul Wig constru �ns MUST be keO at the make any Cll'�anges or ction it is Unlawful to there W,�t�OLjt "L On �(,%Me, L Q or to devi-i- frc,,,q tj&,le Suild. aM 7',',,o F!27.1; g Of !Cial. t ,j Plfzn and sp �-,u TiCd-tioi-S Q or to be �dALI�NOT an aPpro—j any Clty Ordii, �" c �o vic;!ction ance or State Law. No. XF e4) CUPERTINO Building Department FEB 2 6 2015 REVIEWED FOR CODE COMPLIANCE Reviewed By, 4f Zff F,^Aa LI T I NG- troo�< Or, f { .s u z l t �v . E8 2 6 2015 _cE F cooeca�P�� REv\E Neo AN *VISION z f P