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16010021r OF CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10228 ORANGE AVE CONTRACTOR: ptolmin, s PERMIT NO: 16010021 OWNER'S NAME: RAMACHANDRAN BALASUBRAMANIAN AND SU DATE ISSUED: 01/05/2016 OWNER'S PHONE: 4084550538 PHONE NO: / LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL E] COMMERCIAL INSTALL (N) WATER SOFTENER SYSTEM IN GARAGE - License Classlk 6,36`Lie. # �� 2 19-15 9 S CLEAR FROM REQUIRED GARAGE CLEAR FLOOR S(g-SZJIL�F Date l SPACE. Contractor �}=y2Or.)1C-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: I have and will maintain a certificate of consent to self -insure for Worker's o nsation, as provided for by Section 3700 of the Labor Code, for the Sq. Ft Floor Area: Valuation: $3150 ormance of the work for which this permit is issued. ve and will maintain Worker's Compensation Insurance, as provided for by etion 3700 of the Labor Code, for the performance of the work for which this APN Number. (' 8 44. co Occupancy Type: 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 DAYS OF 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 DAYS FROM LAST 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 1 Issued by: �� Date: l granting of this permit. Additionally, the applicant understands ant-tvil comply with all non -point source regulations per the Cupertino Mu al Code, Section 9.18. S RE -ROOFS: Signature -Datej �" 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. ❑ OWNE DER DECLARATION Signature of Applicant: Date: 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) I, 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(x) 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 Dis 12 performance of the work for which this permit is issued. will maintain compliance with the Cupertino Municipal Code, Ch tc 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, S c�-tions 25505, 25533, and 2553 Owner or authorized agent: Date: 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 CONSTRUCTION LENDING AGENCY 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 sliall 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 sliall 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 9.18. Signature Date GENERAL PERMIT APPLICATION MEP COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION � 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 MISC CUPERTINO (408) 777-3228 • FAX (408) 777-3333 • building cDcupertino.orq LUMBING VECHANICAL ❑ELECTRICAL []MISCELLANEOUS PROJECT ADDRESS 1 ®'% '© � P / r �j I � APN OWNERNA1vIE A:PHONE /� l� N E-MAIL STREET ADDRESS i O O IL/4-AJ 6 r � ` C`IT/Y, STA�HZZIP , o 9%5D r� �1 FAX CONTACT NAME JEFF RAINEY PHONE510-427-4260 E MAIL. jeffrey.rainey@aft.net STREETADDRESS 1069 EDGEMERE LANE CITY, STATE, ZIP HAYWARD, CA 945454 FAX510-783-1041 ❑ OWNER ❑ OWNER -BUILDER ❑ OWNER AGENT ❑ CONTRACTOR C4 CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTORNAME LICENSE NUMBER 9L q ! LICENSE TYPE C36 BUS. LIC# COMPANYNAIvffi �� I S� I� E-MAIL FAX ye --i holo ST�2EET ADDRONE. 5ESS CITY, STA ZIP PHZ/�S tv ARCHITECTIENGWEER NAME LICENSE NUMBER BUS. LIC # COMPANY NAME E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE USE OF SFD or DUPLEX [IMULTI-FAMILYPROJECT BUILDING: ❑ COMMERCIAL IN WILDLAND ❑YES URBAN INTERFACE AREA ❑ NO PROJECT IN ❑YES FLOOD ZONE ❑ NO IS TJX BLDG AN El YES EICHLER HOME? ❑ NO DESCRIPTION OF WORK t 5� 1 tJA IC -K 5o FfLnJ 6--2 5 , TOTAL VALUATION: I S D RECEIVED By my signature below, I certify to each of the following: I am the property owner or authorized a act on the property owner's beha ' I ave read this application and the information I have provided is correct. I have read the Description of.Wnd verify it is accurate. I agree to comply W -IM all applicable local ordinances and state laws relating to building construction. ze representati of Cupertino to enter the above -ides tified property for inspection purposes. 5 Signature of Applicant/Agent: Date:If- SUPPLEMENTAL TION REQUIRED OFFICE USE ONLY. ' W . ❑OVERTAE,COUNTER 0. F" ❑ EXPRESS U q : - ; ' STANDARD' ❑ .LARGE ii 4 k`- 1 ` � MAJOR MEPMiscApp_2011.doc revised 06/21/11 CITY OF CUPERTINO EP—W-7a FFF, F.RTIM A TOR — RI TIT DIVISION ADDRESS: 10228 Orange Ave FEE ID DATE: 01105/2016 REVIEWED BY: Phuong APN: 357 18 044 BP#. *VALUATION: 1$3,150 *PERMIT TYPE: Plumbing Permit 1PREPPIPE FPLAN CHECK TYPE: Alteration / Addition / Repair PRIMARY SFD or Duplex USE: # PENTAMATION 1 RPWP PERMIT TYPE: WORK Install (N) water softeners stem in garage -clear from required garage clear floors ace. SCOPE Fee: APPLIANCE / EQUIP TYPE FEE ID QTY/FEE QTY UNITS BP FEES Piping, Water Treatment 1PREPPIPE 0.0 1 # $48 TOTALS: 10TE. This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Pire, Sanitary Fewer District, School District, etc). These.fees are based on the preliminary information available and are only an estimate. Contact the Dept.for aildn'l info, FEE ITEMS (Fee .Resolution 1.1-053.Lff 7/1,113) FEE QTY/FEE MISC ITEMS hm chec'116 Plumb. Plan Check 0.0 hrs $0.00 1.,, Ie(-Plo Fee: Plumb. Permit Fee: IPPERMIT PME UnitFee: $48:00 140-h. 7;rsp. $48.00 Other Plumb Insp. El hrs 1 $48.00 Work Without Permit? 0 Yes 0 No $0.00 Tee: Travel Documentation Fee: ITR,4VDOC $48.00 I 10TE. This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Pire, Sanitary Fewer District, School District, etc). These.fees are based on the preliminary information available and are only an estimate. Contact the Dept.for aildn'l info, FEE ITEMS (Fee .Resolution 1.1-053.Lff 7/1,113) FEE QTY/FEE MISC ITEMS 11an Chec, PME Plan Check: $0.00 1,:ee PME UnitFee: $48:00 PME Permit Fee: $48.00 Administrative Fee: 1ADMIN $45.00 Work Without Permit? 0 Yes 0 No $0.00 Travel Documentation Fee: ITR,4VDOC $48.00 Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $1.00 ......... �� VBTOTAILS- $190.50 $0.00 TOTAL 'FEE: : 1 $190.50 1 Revised: 10/01/2015