15100009CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 22224 VIA CAMINO CT CONTRACTOR-' PERMIT NO: 15100009
OWNER'S NAME: CHARI SRIKUMAR AND DIVYA TRUSTEE 6 W11MQr4 31r. DATE ISSUED: 11/ 2/2015
OWNER'S PHONE: 4088874262 � P� 0 � C1 PHONE NO: �rV 55Wd
LICENSED CONTRACTOR'S DECCLARATION
icense Class Lic. #AJ;_?_13_47
Contractor f " C,91A4r (, J c 6ti Date L O 1 Z . ZU 15
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.
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.
A.
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. Additionall the licant understands and will comply
with all non -point sour atio Cupe i Municipal Code, Section
9.18. A
❑ OWNER -BUILDER DECLARATION
JOB DESCRIPTION: RESIDENTIAL ❑ COMMERCIAL ❑
REMODEL AND RECONFIGURE (E) MASTER BATHROOM
AND
(E) MASTER CLOSET (150 S.F.)
Sq. Ft Floor Area: I Valuation: $11000
APN Number: 32646006.00 1 Occupancy Type:
PERMIT EXPIRES IF WORD IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 7YS I�FROM LAST CALLED INSP CT ON.
Issued by:"�3 Date:/ /lo
RE-ROOFS:
jr 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.
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
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. ti
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 1; Date
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 2 4.
Owner or authorized a of Date: A&
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
CONSTRUCTION PERMIT APPLICATION 15I0000q
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
' I(408) 777-3228 • FAX (408) 777-3333 • building(aDcupertino.org
CUPERTINO ,
F-1NFw (`ONSTRI TcTION ❑ ADDITION ' 1�� ALTERATION / TI ❑ REVISION / DEFERRED ORIGINAL PERMIT #
PROJECT ADDRESS n
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APN # —1r 6
OWNERNAME
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CITY, STATE, ZIPP�1 W/� /
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FAX
CONTACT NAME
PHONE
E-MAIL
STREET ADDRESS
CITY, STATE, ZIP
FAX
OWNER ❑ OWNER -BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAM
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CENSE NUMBER b
LICENSE TYPE
BUS. LIC #
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COMPANY NAME
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CITY, STATE, ZIP� ice(� ) I r
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PHONE
ARCHITECT/ENGINEER NAME
LICENSE NUMBER
BUS. LIC #
COMPANY NAME
E-MAIL
FAX
STREET ADDRESS
CITY, STATE, ZIP
PHONE
DESCRIPTION OF WORK%V
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EXISTING USE
PROPOSED USE CONSTR
TYPE
# STORIES
USE
TYPE
OCC.
SQ.FT.
VALUATION ($)
EXISTG NEW FLOOR
DEMO
TOTAL
AREA AREA
AREA
NET AREA
BATHROOMKITCHEN
fr
REMODEL A x
REMODEL AREA
OTHER
REMODEL AREA
PORCH AREA
DECK AREA
TOTAL DECK/PORCH AREA
GARAGE AREA: DETACH
I
❑ ATTACH
I
# DWELLING UNITS:
IS A SECOND UNIT ❑ YES
SECOND STORY ❑ YES
BEING ADDED? [3NO
ADDITION? []NO
PRE -APPLICATION ❑ YES IF YES, PROVIDE COPY OF
IS THE BLDG AN ❑ YES
RPCWED BY:
O AL VALUATION
PLANNING APPL # ❑ NO PLANNING APPROVAL LETTER
EICHLER HOME? ❑ NO
J� j A Y �, ��jj
0
,.
`�
`l�.Y Oi' LcLL
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By my signature below, I certify to each of the following: I am the property owner or authorizcfd agent to act 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 Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating to building construction. I authorize representatives of Cupertino to enter the above Identified property for Inspection purposes.
Signature of Applicant/Agent:i/"`a Date: i:it
SUPPLEMENTAL INFORMATION REQUIRED
PLAN CHECK TYPE
ROUTING SLIP
oVER-Tlli'�COUNTER
X
� BUILDING PLAN REVIEW
_ New SFD or Multifamily dwellings: Apply for demolition permit for
existing building(s). Demolition permit is required prior to issuance of building
permit for new building.
❑ EXPRESS
❑ PLANNING PLAN REVIEW
_ Commercial Bldgs: Provide a completed Hazardous Materials Disclosure
❑ STANDARD
❑ PUBLIC WORKS
form if any Hazardous Materials are being used as part of this project.
❑ LARGE
❑ FIRE DEPT
_ Copy of Planning Approval Letter or Meeting with Planning prior to
❑ MAJOR
11 SANITARY SEWER DISTRICT
submittal of Building Permit application.
❑ ENVH2ONMENTAL HEALTH
BldgApp_201 1. doe revised 06121111
-' Cb,I
Fm—'�
CITY OF CUPERTINO
FEE ESTIMATOR—BUILDING DIVISION
NOTE: This estimate does not include fees due to other Departments (Le. 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 for addn'1 info.
FEE. ITEMS (Fee Resolution 11-053 Eff. 7/1/13)
ADDRESS: 22224 Via Camino Ct.
DATE: 10/02/2015
REVIEWED BY: PAUL
Mech, Perron Fee;
APN: 326 46 006
BP#:
*VALUATION: j$11,000
*PERMIT TYPE: Building Permit
PLAN CHECK TYPE: Alteration / Repair
PRIMARY SFD or Duplex
USE:
Plumb. Insp. l,ee:
PENTAMATION 1 R3SFDREM
PERMIT TYPE:
WORK
Remodel and Reconfigure E Master Bathroom and E Master Closet 150 S.f.
SCOPE
NOTE: This estimate does not include fees due to other Departments (Le. 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 for addn'1 info.
FEE. ITEMS (Fee Resolution 11-053 Eff. 7/1/13)
LTech, Plan C'he:ckPlumb.
TI
Plan CheckI T
Elec. Plan Check
Mech, Perron Fee;
[Plumb. Permit Fee:
-I
Elec. Permit 1 ee:
L1171'r Alech. In.sp.
Other Plumb Insp.
Other flee. Imp. Lj
Insp. fee:
Plumb. Insp. l,ee:
I;lec. Insp. Fee:
NOTE: This estimate does not include fees due to other Departments (Le. 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 for addn'1 info.
FEE. ITEMS (Fee Resolution 11-053 Eff. 7/1/13)
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee:
$0.00
E5§]s.f.
$645.00
Remodel, Bath (<=300 sfl
IREMRESBAT
Suppl. PC Fee: (j) Reg. 0 OT
0.0
1 hrs
$0.00
PME Plan Check:
$0.00
Permit Fee:
$0.00
Suppl. Insp. Fee -.E) Reg. 0 OT
0.0
hrs
$0.00
PME Unit Fee:
$0.00
PME Permit Fee:
$0.00
Construction Tax:
Administrative Fee:
0
G
Work Without Permit? 0 Yes 0 No
$0.00
Advanced Planning Fee:
$0.00
Select a Non -Residential
Building or Structure
G
i
Trm,el Docuinentalion Fees:
Strong Motion Fee: 1BSEISMICR
$1.43
Select an Administrative Item
Bldg Stds Commission Fee: 1BCBSC
$1.00
_ _ SUBTOTALS:
,
$2.43
$645.00
� TOTAL FEE:
-,
Revised: 07/02/2015
BA". 2.
'CLG. j '
COMMUNITY DEVELOPMENT DEPARTM1 1E
BUILDING DIVISION - CUPERTINO,-
APPROVED
This set of plans and specifications MUST l: 3�
job silo during construction. It is unlawful 't)
changes or alterations on same, or to 1 IE
therefrom, without approval from the Buil c r
ThO stamping of this plan and specifications 1c,
b,:% ha1 trN nprmit nr tn hp Pn gqnnroval of tI
....... .. ... 7
BY
rr DATE VQ
PERMIT NO.
,pt at the
iake any
ate
Official.
ALL NOT
lolation
[te Law.
kOk)6S ° N C7,) �Q -�, c7
X63 O�ZC+ CEC COCX�S FRPL
CUPERTINO
Building Department
im OCT 0 2 2015
(REVIEWED FOR CODE COMPLIANCE
Reviewed By: TAM�Wwvw