15100069 CITY OF CUPERTINO BUILDING PERMIT
(WILDING ADDRESS: 21530 EDWARD WAY CONTRACTOR:R: rR� PERMIT NO: 15100069
OWNER'S NAME: VENKATARAMAN GOPALAKRISHNAN TRUSTEE C V DATE ISSUED: 10/08/2015
OWNER'S PHONE: 6504544538 PHONE NO:
LICENSED CONTRACT'OR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL ❑ COMMERCIAL ❑
REMODEL(E)196 S.F.KITCHEN INCLUDING(N)
License Class Lic.# DESIGNATED GAS LINE(NO STRUCTURAL CHANGES
Contractor _&4 t L v
i
I hereby affirm that In 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: Sq.Ft Floor Area: Valuation:$13000
r 1 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 k PN \u in her:35618022.00 Occupancy Type:
performance of the work for which this permit is issued.
I have and will maintain Worker's Compensation Insurance,as provided for bN
Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued. PERMIT EXPIRES IF WORK IS NOT STARTED
APPLICANT CERTIFICATION WITHIN 180 DAYS-QE PERMIT ISSUANCE OR
I certify that 1 have read this application and state that the above information is 180 D O CALLED INSPECTION.
correct.1 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 s
indemnify and keep harmless the City of Cupertino against liabilities,judgmen
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 RE-ROOFS:
all non-point source regul 'o per the Cupertino Municipal Code,Section 9.18.
� � Ali roofs shall be inspected prior to any roofing material being installed.If a roof is
tiignatrtre Date installed without first obtaining an inspection,1 agree to remove all new materials for
inspection.
❑ OM NER-BUILDER DECLARATION Signature of Applicant: Date:
I hereby affirm that 1 am exempt from the Contractor's License Law for one of ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
the following two reasons:
r 1,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 HAZARDOUS MATERIALS DISCLOSURE
sale(Sec.7044,Business&Professions Code) 1 have read the hazardous materials requirements under Chapter 6.95 of the
2 1,as owner of the property,am exclusively contracting with licensed contractors to California Health&Safety Code,Sections 25505,25533,and 25534. 1 will maintain
construct the project(See.7044,Business&Professions Code). compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
Safety Code,Section 25532(a)should 1 store or handle hazardous material.
I hereby affirm under penalty of perjury one of the following three declarations: Additionally,should 1 use equipment or devices which emit hazardous air
r. 1 have and will maintain a Certificate of Consent to self-insure for Worker's contaminants as defined by the Bay Area Air Quality Management District 1 will
Compensation,as provided for by Section 3700 of the Labor Code,for the maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
performance of the work for which this permit is issued.
Health&Safety Code,Sections 25505,25533,and 25534.
2. I have and will maintain Worker's Compensation Insurance,as provided for by Owner or authorizeda
Section 3700 of the Labor Code,for the performance of the work for which this Date: `� ��
permit is issued.
s. I certify that in the performance of the work for which this permit is issued,l shall CONSTRUCTION LENDING AGENCY
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 I hereby affirm that there is a construction lending agency for the performance of work's
become subject to the Worker's Compensation provisions of the Labor Code,I Rx which this permit is issued(Sec.3097,Civ C.)
must forthwith comply with such provisions or this permit shall be deemed Lender's Name
revoked. Lender's Address
APPLICANT CERTIFICATION ARCHITECT'S DECLARATION
I certify that I have read this application and state that the above information is I understand my plans shall be used as public records.
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 licensed Professional
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
CONSTRUCTION PERMIT APPLICATION
C COMMUNITY DEVELOPMENT DEPARTMENT- BUILDING DIVISION
10300 TORRE AVENUE- CUPERTINO, CA 95014-3255
(408)777-322B- FAX(408)777-3333- building aQcupertino.org /
CUPERTINO 1 < I�
❑NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION/TI ❑ REVISION/DEFERRED ORIGINAL PERMIT
PROJECT ADDRESS ZI53'0 EDWARD
7 w/44, CuPFRr INo,c A APN a
OWNER NAME PH ON
GnoPA�AKIQ I SRrVW VENKIFThRAMAnI 65��46-4-4673 Q VEW"TNRATI®4M41L. COM
STREET ADDRESS CITY, STATE,ZIP FAX
-Z%1F3o EowAPP WArl OWER NO CA 45-oiIf
CONTACT NAVE Tt R A, w�� PHONE E-MAIL
R I'i �F{ 5-(0) 2a 9-b o 84 NTr4ER YkRoo.CAM
STREET ADDRESS CITY,STATE, ZIP r< (O 50 0- O7 �j
a
At 14,7 O(A DEN X%Vr K N1,oNT GFS Q ks3 8
OWNER ❑ OWNER-BUILDER ❑ OW17.R AGENT CONTRACTOR ❑CONTRACTOR.AGENT ❑ ARCHITECT /❑l ENGL,,TzR ❑ DE,,-ELOPER ❑ TENAN-T
CONTRACTORNAME JI N NA 1 A A�� LICENSENU,OFR Q n 2 Q LICENSE TYPF vIGNF BUS.LIC k
J I'� A j� 3 1 JIIbIN&A N•(
COMPANY NA1,4E E-MAIL
fN?t(AE12 CoNSTRUCTcoW P&J-rl(AER CQ YAHOO-CZt"t FAX5t�) 50O' o58�r
STREET ADDRESS CITY,STATE,ZIP PHO1
til OCAPtN DKtvE oNT CA q463 9 Sto 2019- 6n94
ARCIUTECT/ENGINEER NAME LICENSE NUMBER BL'S LIC k
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
DESCRIPTION OF WORK
QEMo�EL C?ClSfJN4 KITCOfCN filo S'rRvcTcJRAl- Ck-41AES
L( ►�
EXISTING USE PROPOSED USE CONSTR TYPE I #STORIES
/1 USE TYPE OCC. SQ.FT. VALUATION(S)
EXISTG NEW FLOOR DEMO TOTAL
AREA AREA AREA NET AREA
BATHROOM KITCHEN OTHER
REMODEL AREA REMODEL AREA l6 'f REMODEL AREA
PORCH AREA DECK AREA TOTAL DECKIPORCH AREA GARAGE AREA: LJDETACH
❑ATTACH
k DWBLLING uNrrS: IS A SECOND UNIT Q YES SECOND STORY ❑YES
BEING ADDED' NO ADDrr10N' �2J0
FRF-APPLICATION []YES IF YES,PROVIDE COPY OF IS THE BLDG - _ •> 70 T.;L VA-LUATION:
PLANNING APPL: ❑NO PLANNING APPROVAL LETTER EICHLER H ;&NO - s
1 '000 ' CID
By my signature below,I certify to each of the following: I am the property o. r author' ge on the property owner's behalf. I have read this
application and the information I have provided is correct. I have read the Description of Nkro rify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating to ing construction. I authorize representatives of C ertino to enter the above-identif d property for inspection purposes.
Signature ofApplicant/Agent: Date: S
SUPPLEMENTAL IN'FORIvIATION REQUIRED __s ,_'Pi.ANCi�CKTHTE {� .z,.RouTLNG sur
New SFD or Multifamily dvvellings: Apply for demolition permit for s �;
�Q�OVERTHECOUI,TER BUIIDL\G PLANREENV
existing building(s). Demolition permit is required prior to issuance of building : VI`
permit for new building. oo # ", J
CYPRESS s -� # E ❑ NIE«
_Commercial Bldgs: Provide a completed Hazardous Materials Disclosure � srDARn ❑ PLI LIc t�ot<Ls
form if any Hazardous Materials are being used as part of this project. �� -
❑Ili�ARGF z FIRE DEP
_Copy of Planning Approval Letter or Meeting with Planning prior to -
submittal of Building Permit application. - oR { �_` ❑.sAl.Tra RY SEwERDISTBJ
❑'E?\VIRONMENTA UkEALTH:
BldgApp_2011.doc revised 06/21/11
CITY OF CUPERTINO
FEE ESTIMATOR - BUILDING DIVISION
ADDRESS: 21530 EDWARD WAY DATE: 10/08/2015 REVIEWED BY: MELISSA
APN: 356 18 022 BP#: 'VALUATION: 1$13,000
PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration / Repair
PRIMARY SFD or Duplex PENTAMATION 1 R3SFDREM
USE: PERMIT TYPE:
WORK REMODEL E 196 S.F. KITCHEN INCLUDING N DESIGNATED GAS LINE NO STRUCTURAL
SCOPE CHANGES
F_
Lj L-] I
NOTE: This estimate does not include fees due to other Departments(i.e. Planning,Public Works, Fire,Sanitary Sewer District,School
District,etc. . Thesefees are based on the preliminarl information available and are only an estimate. Contact the Dept for addn'l info,
FEE ITEMS (Fee Resolu/iun 11-053 E,(/: 7/'1173) FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 F196 s.f. Remodel, Kitchen(<=300 sf)
Suppl. PC Fee: Q Reg. Q OT 0.0 hrs $0.00 $645.00 IREMRESKIT
PME Plan Check: $0.00
Permit Fee: $0.00
Suppl. Insp. Fee.e Reg. Q OT 0,0 hrs $0.00
PME Unit Fee: $0.00
PME Permit Fee: $0.0 0
' Ull.ti1/'ZIl'1lUn /1L1.
0
Work Without Permit? O Yes 0 No $0.00
Advanced Planning Fee. $0.00 Select a Non-Residential Q
/rel Docuurerl/atiun /''ecus. Building or Structure O
Strong Motion Fee: IBSEISMICR $1.69 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $1.00
SUBTOTALS: $2.69 $645.00 TOTAL FEE: $647.69
Revised: 10/01/2015
Building Department
City Of Cupertino
L31 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 — IMA H 45oiy PERMIT# /S / U O
OWNER'S NAME60ALAKRISHNAI-4 VENKA-rAkAM-41,1 PHONE#
GENERAL CONTRACTOR BUSINESS LICENSE#
ADDRESS: ITY/ZIPCODE: –
*Our municipal code req res all businesses working in the city to have a City of Cupertino business license.
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.
1 am not using any subcontractors: - v
Signature I Date
Please check applicable subcontractors and complete the following information:
j/ 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/Contractor Signature Date
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