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15030187pr 10% CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 21618 ROSARIO AVE CONTRACTOR: MOHAN PERMIT NO: 15030187 PARTHASARATHY OWNER'S NAME: CUPERTINO, CA 95014 PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL ❑ COMMERCIAL REMODEL (E) HALL & MASTER BATHS, NO License Class Lic. # STRUCTURAL CHANGES (72 S.F.) Contractor Date 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: $15000 I have and will maintain Worker's Compensation Insurance, as provided for by APN Number: 35619015.00 Occupancy Type: Section 3700 of the Labor Code, for the performance of the work for which this 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 DAY F 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 DAY T 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 ed by: ate: `3 � O 1 granting of this permit. Additionally, the applicant understands and will comply with all non -point source regulations per the Cupertino Municipal Code, Section RE -ROOFS: 918. Signature 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 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, will do the work, and the structure is not intended or offered for sale (Sec.7044, Business & Professions Code) 1, 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. 1 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 Section 3700 of the Labor Code, for the performance of the work for which this the Health & Safety Code, Sections "— Date: d �° 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 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 918. �� Date d �� � �S Signature �� CITY OF CUPERTINO r+r.Tr irorr7AR A T/1D RITII illNr' il>V><C><(1N ,Wch, Plan Check I'Iratrrb. Ilan Cheek plea. flan Check L9ecfr. Permit Fee: Plump. Permit Fee: Elec Permit Fee Other ;i/ech. Trap Other Plumb Ins/,z C)rtaef Elec. Insp. Li �feck. lnsp. Fee: Plumb, Lisp. Fee: Llec. Insp. Fee: C—u rlictrirt Rrhnnt NOTE: This estimate does not mcluae fees aue to omer vepurtnenea 1e.e. K eus.eeesg, I»��� .• �• - •• __.. __ •_v_ ___� _ -e.. ,...d.....t., r s.mnt tbo Wont fnrm/dn°t ini0_ District, eta). Lnese fees are Dasea on ine reuriureur FEE ITEMS Lee Resolution 11-053 E . 7/1/13) X. A:IJ — -__ �_ ___________ MISC ITEMS ADDRESS: 21618 ROSARIO AVE DATE: 03/30/2015 REVIEWED BY: MELISSA jui APN: 35619 015 BP#: *VALUATION: $15,000 *PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration / Repair PRIMARY SFD or Duplex $0.00 PENTAMATION 1 R3SFDREM I PERMIT TYPE: USE: Permit Fee: $0.00 WORK REMODEL E HALL & MASTER BATHS NO STRUCTURAL CHANGES hrs $0.00 SCOPE ,Wch, Plan Check I'Iratrrb. Ilan Cheek plea. flan Check L9ecfr. Permit Fee: Plump. Permit Fee: Elec Permit Fee Other ;i/ech. Trap Other Plumb Ins/,z C)rtaef Elec. Insp. Li �feck. lnsp. Fee: Plumb, Lisp. Fee: Llec. Insp. Fee: C—u rlictrirt Rrhnnt NOTE: This estimate does not mcluae fees aue to omer vepurtnenea 1e.e. K eus.eeesg, I»��� .• �• - •• __.. __ •_v_ ___� _ -e.. ,...d.....t., r s.mnt tbo Wont fnrm/dn°t ini0_ District, eta). Lnese fees are Dasea on ine reuriureur FEE ITEMS Lee Resolution 11-053 E . 7/1/13) sis vsiisussys ......•....� FEE -•• - »-- QTY/FEE -__ �_ ___________ MISC ITEMS Plan Check Fee: $0.00 = s.f. Remodel, Bath (<=300 sf) $645.00 IREMRESBAT Suppl. PC Fee: Reg. OOT 0.0 hr's $0.00 PME Plan Check: $0.00 Permit Fee: $0.00 Suppl. Insp. Fee -.0 Reg. ® OT f 0.01 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 Consirtrction Tax: Administrative I ee: Work Without Permit? Yes o No $0.00 _O Advanced Planning Fee: $0.00 Select a Non -Residential Building or Structure I O A Trai,el Doeumenlation Fees: Strom Motion Fee: IBSEISMICR $1.95 Select an Administrative Item Bldg Stds Commission .Fee: IBCBSC $1.00 3 $2.95 $645.00 t' T TAL FEE: ; $647.95 � RCv IJCu. Vu iIt/ " I.