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15090006CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 1164 ELMSFORD DRCONTRACTOR: PERMIT NO: 15090006 ,� r OWNER'S NAME: AVADHANAM NAGARAJA AND RAMAVARJULA DATE ISSUED: 09/01/2015 OWNER'S PHONE: 4084251497 PHONE NO: U LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL E] COMMERCIAL INSTALL (N) DESIGNATED GAS LINE FROM METER TO License Class Lic. # 617 2 OVEN/STOVE Contractor-" 1<116H" ✓ATNAR- _` 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. rI have and will maintain Worker's Compensation Insurance, as provided for by �ection 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 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, costs, and expenses which may accrue against said City in consequence of the granting of this permit. Additionally, the applicant understands and will comply with all non -point source regulations per the Cupertino Municipal Code, Section 9.18. Signature Date ❑ OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: 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 construct the project (Sec.7044, Business & Professions Code). I hereby affirm under penalty of perjury one of the following three 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. 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 Sq. Ft Floor Area: I Valuation: $1200 APN Number: 36209011.00 1 Occupancy Type: PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF VEMMU ISSUANCE OR 180 DAYS F LED INSPECTION. Date f RE -ROOFS: 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. Signature of Applican Date: F ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER HAZARDOUS MATERIALS DISCLOSURE 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 compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Section 25532(a) should I store or handle hazardous material. Additionally, should I use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management District I will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Sections 25596, 25533, and 25534. Owner or authorized agent: ��T Date: CONSTRUCTION LENDING AGENCY become subject to the Worker's Compensation provisions of the Labor Code, I mustI 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 I 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, costs, and expenses which may accrue against said City in consequence of the granting of this permit. Additionally, the applicant understands and will comply with all non -point source regulations per the Cupertino Municipal Code, Section 9.18. Signature Date ARCHITECT'S DECLARATION I understand my plans shall be used as public records. Licensed Professional CUPERTINO GENERAL PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 • buildinC c( Cuoertino.org n 944 M is MEPAliscApp_2011.doc revised 06121/11 CITY OF CUPERTINO FEE ESTIMATOR — BUILDING DIVISION ka,ADDRESS: 1164 ELMSFORD DR DATE: 09101/2015 REVIEWED BY: MELISSA UNITS APN: 362 09 011 BP#: "VALUATION: 1$1,200 PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration / Addition / Repair PRIMARY SFD or Duplex USE: # PENTAMATION 1 RPGAS PERMIT TYPE: WORK INSTALL N DESIGNATED GAS LINE METER TO OVEN/STOVE SCOPE Suppl. Insp Fee APPLIANCE / EQUIP TYPE FEE ID Plumb. Plan Check 0.0 1 hrs $0.00 QTY UNITS BP FEES Elec. Permit Fee: Piping, Gas <=4 Outlets 1 PGASRES ,firer h.7ec. Insp. 1 # $72 Permit .Fee: Suppl. Insp Fee PME Unit Fee: $72.00 PME Permit Fee: $48.00 Construction Tux.' Administrative Fee: IADMIN $45.00 Work Without Permit? © Yes (F) No $0.00 TOTALS: Travel Documentation Fee: ITRA VDOC $72.00 Strong Motion Fee: IBSEISMICR NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School District, etc.). These fees are based on the preliminary information available and are only an estimate. Contact the Dept/or addh 7 info. FEE ITEMS (Fee Resolution 11-033 e 7/1/13/ .11ech. Plan Check Plumb. Plan Check 0.0 1 hrs $0.00 raec. Plan Check 'i -tech. Pern r'r l , : Plumb. Permit Fee: IPPERMIT Elec. Permit Fee: Other A1ech. Insp. Other Plumb Insp. 0.0 hrs $48.00 ,firer h.7ec. Insp. t tech. Insp. Fee: PME Plan Check: "Jec. Insp. 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 fees are based on the preliminary information available and are only an estimate. Contact the Dept/or addh 7 info. FEE ITEMS (Fee Resolution 11-033 e 7/1/13/ FEE QTY/FEE MISC ITEMS Plait Check Fee: Suppl. PC Fee PME Plan Check: $0.00 Permit .Fee: Suppl. Insp Fee PME Unit Fee: $72.00 PME Permit Fee: $48.00 Construction Tux.' Administrative Fee: IADMIN $45.00 Work Without Permit? © Yes (F) No $0.00 Athwncec/ Planning Fees: Travel Documentation Fee: ITRA VDOC $48.00 Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item Bldg Stds Commission Fee: 1BCBSC $1.00 SUBTOTALS: $214.50 $0.00 TOTAL FEE: 1 $214.50 Revised: 07/02/2015 SMOKE / CARBON MONOXIDE ALARMS OWNER CERTIFICATE OF COMPLIANCE COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 �y CUPERTINO Address PURPOSE This affidavit is a self -certification for the installation of all required Smoke and Carbon Monoxide Alarms for compliance with 2013 CRC Section R314, 2013 CBC Sections 420.6 and 907.2.11.2 where no interior access for inspections are required. GENERAL INFORMATION Existing single-family and multi -family dwellings shall be provided with Smoke Alarms and Carbon Monoxide alarms. When the valuation of additions, alterations, or repairs to existing dwelling units exceeds $1000.00, CRC Section R314 and CBC Sections 907.2.11.5 and 420.6 require that Smoke Alarms and/or Carbon Monoxide Alarms be installed in the following locations: AREA SMOKE ALARM CO ALARM Outside of each separate sleeping area in the immediate vicinity of the bedroom(s) X X On every level of a dwelling unit including basements I X I X Within each sleeping room I X Carbon Monoxide alarms are not required in dwellings which do not contain fuel -burning appliances and that do not have an attached garage. Carbon monoxide alarms combined with smoke alarms shall comply with CBC Section 420.6 and shall be approved by the Office of the State Fire Marshal. Power Supply: In dwelling units with no commercial power supply, alarm(s) may be solely battery operated. In existing dwelling units, alarms are permitted to be solely battery operated where repairs or alterations do not result in the removal of wall and ceiling finishes or there is no access by means of attic, basement or crawl space. Refer to CRC Section R314 and CBC Sections 907.2.11.4 and 420.6.2. An electrical permit is required for alarms which must be connected to the building wiring. As owner of the above -referenced property, I hereby certify that the alarm(s) referenced above has/have been installed in accordance with the manufacturer's instructions and in compliance with the California Building and California Residential Codes. The alarms have been tested and are operational, as of the date signed below. I have read and agree to comply with the terms and conditions of this statement Owner (or Owner Agent's) Name: Signature ........... M'""_. ................................................... Date: 9....v....... Contractor Name: Signature................................................................... Lic.#...................................... Date: ...................' Smoke and COform.doc revised 03/18/14 D)S