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CITI OF CUPERTINO
BUILDING DIVISION PERMIT =� 1 � x
BUILDING ADDRESS: PERMIT NO.
6676 JOHN DR TBD — TO BE DETERMINED 07030318
OWNER'S NAME: PERMIT LSSUEDATE
RAMA KRISHNA DEVISETTI 07/23/2007
PHONE T N zT my n v SANITARY NO. CONTROL NO.
ARCHTTECUENGINEER: BUILDING PERMTTINFO
BLDG ELECT PLUMB MECH
ZLICENSED CONTRACTOR'S DECLARATION
3 Job Description
1 hereby affirm that I am licensed under provisions of Chapter 9(commencing
y with Section 7000)of Division 3 or the Business and Professions Code,and my license is ADD 998 , LIVING/DINING/BEDROOM,CONVERT
`n in cull force and effect License Class Lie.q DETACHED GARAGE TO ATTACHED.MASTERBATH PORCH 40 '
y Date Contractor _
ARCHf7'ECTS DECLARATION REMODELING ENTIRE HOUSE 1 , 663 ' CONVERTING
I understand my plans shall he used as public records
U
N Licensed Professional
OWNER-BUILDER DECLARATION
1 hereby affirm that t am exempt from the Contractor's License Law for the
oC following reason.(Section 7031.5,Business and Professions Code:Any city or county
ti which requires a permit to construct,alter,improve,demolish•nr repair any structure
prior to its issuance,also requires the applicant for such permit to file a signed statement
t] that he is licensed pursuant to the provisions of the Contractor's license Law(Chapte 9 Sq.Ft. Floor AreaValuation
e (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
$383028
that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty or Number Occupancy Type
not more than five hundred dollars($500). 36923008
❑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
and Professions Code:The Contractor's License Law does not apply to an owner of Required Inspections
property who builds or improves thereon,and whodoes such work himself or through his
own employees,provided that such improvements are not intended or offered for sale.If.
however,the building or improvement is sold within one year of completion,the owner-
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑I.as owner of the property.am exclusively contracting with licensed contractors to
concoct the project(Sec.7044,Business and Professions Conk:)The Contractor's Li-
cense Law docs not apply to an owner of property who builds or improves thereon,and
who contracts for such projects with a contractors)licensed pursuant to the Contractors
License Law.
C1 am exe der c .B&P C for rens
Owner � Date
0 7 23
W A I'4"DEeLARATION
1 hereby affirm under penalty of perjury one of the following declarations
❑1 have and will maintain a Certificate of Consent to self-insure for Worker's Compen-
sation,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 required by Section
3700 of the labor Code•for the performance of the work for which this permit is issued
My Worker's Compensation Insurance carrier and Policy number are:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed it the permit is(crone hundred dollars($100)
or less.)
I certify that in the performance of t e work fo which this permit is issued.1 shall not
employ any person in any ma es 'r�b (jj to the Workers'Com crrsation
Laws of Califs i.Date V
Applicant
NOTICE TO A P CANT:If,atter making this Certificate of Exemption,you should
became subject to the Worker's Compensation provisions of the Labor Code,you must
1 z forthwith comply with such provisions or this permit shall be deemed revoked.
C)
CONSTRUCTION LENDING AGENCY
4 1 hereby affirm that there is a construction lending agency for the performance of
' > the work for which this permit is issued(Sec.3097,Civ.C.)
QLender's Name
z Lender's Address
O 1 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 iaws relating to
U building construction.and hereby authorise representatives or this city to enter upon the
y L7a ahovc-mentioned property for inspection purposes.
a (We)agree to save,indemnify and keep harmless the City of Cupertino against
liabilities,judgments.costs and expenses which may in any way accrue against said City
z in contsequcnce oC the granting of this permit
APPLIC ER 3,AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOUR
07-)X3 d Re-roofs
Signature of pp icon o r Dale
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code,Chapter 9.12•and the Health and Satiety
Code,Section 25532(a)?
❑Yes [3 No All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building occupant nese equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes ❑No
I have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health&SafetyCod c,Sections 25505.25533 and 25534.1 understand thatif the building
docs c �=iisLswua.;=c.l.ic
lity to notify the occupant of the
reqs; e w' evfncaic ooff.Oc 2 Signature of Applicant Date
7 All roof coverings to be Class "B"or better
R
CITY OF CUPERTINOO
.w
�,n°F PERMIT APPLICATION FORM
cu
PERTINO
ADDITION/REMODEL -j
APN # �� �;, Date:
Building Address: 6 6 5o kn DY
Mailing Address (if different from building address): q-1 Cc;l.Ytcr A
foe_0 Ck4-K , GA `� 4-S6 D
Owner's Name: 1_0_ Phone#:
fkvncLK-r")SVvAa �Wo5�=���&
Contractor: Phone: State License#:
Fax:
Contact: B Phone:(6'p)3�-0229 Cupertino Business License#:
DS Wl1 Fax:(4f-C)443--�� 12—
Building Permit Info: 5 I ovi I kuii1 k� kP-�xS-__
Bldg ❑ Elect ❑ Plumb ❑ Mech ❑
Job Description:
What is being added? ���Q
L► j�t��w ��,�,,� � -��l-i�c� bid ►'�c�j ►�a.k-i�' dl�c �D
What is being remodeled? a �JYOC
-77
Residential �9 Commercial ❑
Remodel Includes Re-Roof: Yes No ❑ J� /
Remodel Includes Structural: Yes X No ❑
Square Footage:
Addition: �A 9 Remodel: 14 C3> X 100,75 Garage'
Porch: C-Q k 3', S_/ Deck: Other:
Cost of Project: _-C I ao D Occupancy Group:
Type of Construction: Please check this box if the project is a
second-story addition: ❑
Project Size: Standard '�I Large ❑ Major ❑
*For office use only*
❑ Over the counter
1 of 3
Community Development
x 10300 Torre Avenue
Cupertino CA 95014
' Telephone(408)777-3228
CITY OF Fax(408)777-3333
CUPEKTINO
Building Department
JOB ADDRESS:(o � � ��� PERMIT # Q
3 C)3, �
OWNER'S NAME: PHONE #
GENERAL CONTRACTOR: FAX #
clez.
\/ I am not using any subcontractors: e •5 0�
Signature Date
Please check applicable subcontractors and complete the following information:
SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets &Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring: Carpeting
Linoleum/ Wood
Glass/ Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
)/-4 ( 1(.
Owner Contractor Signa "e Date