15100185I CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 20446 VIA PORTOFINO I CONTRACTOR: TRENCHFREE INC PERMIT NO: 15100185
OWNER'S NAME: ADITHAM RADHAKRISHNA AND JINDAL ANI
OWNER'S PHONE: 4082348069
®-ij LICENSED CONTRACTOR'S DECLAARATION
License Class Ok 611, a
Lic. # 6 36r011.E
Contractor Tr rir A N& , 2AC. Date " Z_ S
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:
1 . 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.
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 01-yS r
❑ OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons:
t. 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)
2. 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.
2. 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.
3. 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
become subject to the Worker's Compensation provisions of the Labor Code, I
must forthwith comply with such provisions or this permit shall be deemed
revoked.
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.
Date
PO BOX U I DATE ISSUED: 10/22/2015
SAN JOSE, CA 95151 1 PHONE NO: (408) 726-7926
JOB DESCRIPTION: RESIDENTIAL ❑ COMMERCIAL ❑
INSTALL (N) PROPERTY LINE CLEANOUT **CUPERTINO
SANITARY**
SANITARY
Sq. Ft Floor Area: I Valuation: $2000
APN Number: 31 (100 116 1. fld I Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DDS FROM LAST CALLED INSP CTI N.
Issued by: ��"' Date: ' 0 "
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 Applicant: Date:
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 25505, 25533, and 25534.
Owner or autligrized agent: n r�
Date:
z�
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of work's
for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
Lender's Address
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Licensed Professional
CUPERT[t40
GENERAL PERMIT APPLICATION 1,��Op���
COMMUNITY DEVELOPIdENT DEPARTMiENT • BUILDING IVISION
10300 T ORRE AVENUE - CUPERTINO, CA 95014-3255
(408) 777-3228 • FAX (408) 777-3333 • buildina(a)cuoel;ino.org
I b/'ECl4ANICAL ❑ ELECTRICA.L ❑ ]V ISCELLANTEOUS
PROSECT ADDRESS e)ilU I N All � °PN #
OP KEE.R. A.I✓:ERh Nirko-
I
q
PHOi\� E-I✓�d.IL J o-64
13 Lf `YET ( 00. i:9�,
STREETADDRESSr n O��/ A p � u
(� t� ,y�
CITY, STATE, ZIP r / / Q py,I
(/bl C./T
I FAX
CONTACT N.iMiE
JL-ta^ I1 r
( PHOk� ^ ^�Iis u
E T✓� I?r
%%%'(�
STREET ADDRESS 176bt7 L / ��,Vl �,4rL ' W'.
CITY, STATE, ZiP /� CrI ! JV 3
FAX
❑ OCR m ❑ om\—r. t -BUILDER ❑ Ow\—rR AGD.'T
CON-7—kCTOR ❑ CO`.TP 4CTOR AG-- ,•T ❑ ARCHITECT ❑ =NGL:= -E2 ❑ DF cLOPE:k ❑ i _ � a�T
CONTR4CTOR NAj\L �(
' � Fie
I LICENSE NTUI SER I LICENSE �P�
CC��
I BL S. LIC r �I� 6
l "l
COI✓,PAAY N.4✓.E
E- 4II
i Q. AM
I F.4X
STREET ADDRESS `
CITY, STATE, ZiPAt ^ 4, It �1 903
I P?iONE'
A-RCMTECTIENGIDNEER N.4N.E
LICENSE NLMBER
I BUS. LIC r
COl✓PANY NAI✓,E
E -]✓AIL
I FA.Y
STREET.4DDRESS
( CITY, STATE, ZIP
I PHONE
USE OF ❑ SFD or DL-PLEX ❑ 1J.ULTI-F.AJ MY PROJECT LN wILDLA KD ❑ Yas PROj= IN ❑ YES
BUMDI.'1G: ❑ COI.Q��R' CL4L I LP3.1N L2N'T-RFACE,1 9.EA ❑ NO FLOOD ZOKEE ❑ NO
IS THE BLDG AN ❑ - _S
I FICKLER HOMc? ❑ NO
DESCRIPTION OF R'ORK
der
M
TOTAL VALUATION: F/�'Q
«
RECEI�D na ^i
By my signature below, I ce?iiy to each of the following:
application and the Lzfonnation I have provided is correct.
ordinances and state laws relating to ilding construction.
Signature of A.pplicant/Agent:
I au he property owner or auuorized agent to act on the p operty owner's behalf. I have read this
I have read the Description of Work and veri.`y it is accurate. I agree to comply with all applicable local
I authorize representatives of Cupertino to enter the aboove-iddcntified propm-ty for inspection purposes.
Date: tap, `1 -
—
SUPPLEMENTAL R-.FOR✓lATION REQULP.ED
MEFh!iscApp_2011.doc revised 06/21/11
CITY OF CUPERTINO 151001�
Iiy�/yl FEE ESTIMATOR -BUILDING DIVISION
kaADDRESS:
20446 VIA PORTOFINO
DATE: 10/22/2015
REVIEWED BY: PAUL
UNITS
l APN: 316 01 151
BP#:
*VALUATION: 1$2,000
°PERMIT TYPE: Plumbing Permit
PLAN CHECK TYPE: Alteration / Addition / Repair
PRIMARY SFD or Duplex
USE:
#
PENTAMATION 1 RPSS
PERMIT TYPE:
WORK
INSTALL N PROPERTY LINE CLEANOUT "CUPERTINO SANITARY"
SCOPE
APPLIANCE / EQUIP TYPE
FEE ID
Plan Check 0.0 hrs $0.00
QTY
UNITS
BP FEES
Flee. Permit Fee.
Sewer, Sanitary
1 PRSEWER
Other E'lec. Insp.
1
#
$25
PME Unit Fee:
$25.00
PME Permit Fee:
$48.00
Administrative Fee: (ADMIN
$45.00
Work Without Permit? O Yes (F) No
$0.00
TOTALS:
Travel Documentation Fee: ITRA VDOC
$25.00
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 Dreliminary information available and are only an estimate. Contact the Dept for addn7 info.
FEE ITEMS (Fee Resolution I1-653 E . 7/1/13)
ikrch. Plan CheckPlumb.
Plan Check 0.0 hrs $0.00
}7ec. New (.`heck
Flech. Permit /,ee.
Plumb. Permit Fee: IPPERMIT
Flee. Permit Fee.
iher.Alech. hasp.
Other Plumb Insp. 0.0 hrs $48.00
Other E'lec. Insp.
llech. Insp. Fee:
''limb. Imp. Fee:
flee. 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 Dreliminary information available and are only an estimate. Contact the Dept for addn7 info.
FEE ITEMS (Fee Resolution I1-653 E . 7/1/13)
FEE
QTY/FEE
MISC ITEMS
'hin Check 1' e i
IIpjv/. PC Fee
F71
PME Plan Check:
$0.00
PME Unit Fee:
$25.00
PME Permit Fee:
$48.00
Administrative Fee: (ADMIN
$45.00
Work Without Permit? O Yes (F) No
$0.00
ttivcinced .Planning Fees:
Travel Documentation Fee: ITRA VDOC
$48.00
Strong Motion Fee: IBSEISMICR
$0.50
Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC
$1.00
SUBTOTALS:
$167.50
$0.00 TOTAL FEE:
$167.50
Revised: 10/01/2015