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CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFURMATIO,
BUILDING ADDRESS: PERMIT NO.
1217 WEYMOUTH DR TBD — TO BE DETERMINED 08090151
OWNER'S NAME: PERMIT L95UF DATE
SRIDHAR SODEM 09/23/2008
PHONE: SANITARY NO, CONTROL NO.
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
O p LICENSED CONTRACTOR'S DECLARATION
Iu p I hereby affirm that I am licensed under provisions of Chapter 9(commencing Job Description
:z 1 with Section 7000)of Division 3 of the flusinrss and Professions Codc,and my license is RMDL BTHRMS (2—12 7 S Q)KTC HN(1—3 0 S Q) NON—S TRCTRL,
h y in full force and effect.
License Class Lic.rt ELEC/MECH/PLMBNG
F w Date Contractor
ARCHITECTS DECLARATION
5K< I understand my plans shall be used as public records
)yU
C y Licensed Professional
0 OWNER-BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractors License Law for the
j p O following reason.(Section 7031.5,Business and Professions Code:Any city or county
m(ii which requires a permit to construct,alter,impravc,demolish,or repair any structure
prior to its issuance.also requires the applicant for such permit to file a signed statement
.z< that he is licensed pursuant to the provisions of the Contractor's(rValuation
F ccnse Law(Chapter 9 Sq.Ft.Floor Area
n (commencing with Section 7000)of Division 3 of the Business and Professinns Code)or $13000
that he is exempt therefrom and the basic for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty ofNumber Occupancy
not more than rive hundred dollars(x500). 36210031 P Y Type
p 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 sale(Sec.7044,Business
and Professions Code:The Contractors License Law does not apply to an owner of Required Inspections
property who builds or improves thereon,and who does 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.).
W.I,as owner of the property,am exclusively contracting with licensed contractors to
onstmct the project(Sec.7044,Business and Professions Code:)The Contractor's Li-
cense Law dors not apply to an owner of property who builds or improves thereon,and
who contracts for such projects with a contractor(s)licensed pursuant to the Contractor's
License Law.
❑1 am exempt under Sec ,B&P C for this reason
Owner /\.- l- Date
-WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
❑1 have and will maintain a Ccr ifimm of Consent to self-insure for Workers 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 Workers Compensation Insurance carrier and Policy number arc:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
('Phis section need not be completed if the permit is forone hundred dollars(x100)
or less.) "
1 certify that in the performance of the work for which this permit is issued,1 shall not
employ any person in any manner to/bee m sub'ect to the Workers'Compensadon
Laws of Califomi Datc
Applicant r1�� F.i!�-,-���M
NOTICE TO APPLICANT: after making this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you must
,z forthwith comply with such provisions or this permit shall be deemed revoked.
4, CONSTRUCTION LENDING AGENCY
Cn
1 hereby affirm that there is a construction lending agency for the performance of
Yr > the work for which this permit is issued(Sec.3097,Civ.C.) '
Lenders Name
Lenders Address
O 1 certify that I have read this application and state that the above information is
y COMM I agree to comply with all city and county ordinances and state laws relating to
Ubuilding construction,and hereby authorize representatives of this city to enter upon the
W ahovc-mcntoned property for inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
fn liabilites,judgmens,costs and expenses which may in any way accrue against said City
in consequence of the granting of this permit.
N. APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date / 2'J
SOURCE REGULATIONS.
�A— `��` QgJ2310- Re-roofs
Signature of Applican/Contractor Dare
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 Safety
Code,Section 25532(a)?
❑Yes 6-K-0All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit hazardnus air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
Distract?
C3 YC
1 have read the hazardous materials requirements under Chapter 6.95 of the Ca)iror-
nia Health&Safety Codc,Sections 75505,25533 and 25534.1 undcrsrand that if the building
does not currently have a tenant,that it is my responsibility,to notify the occupant of the
requirements which must be met prior to issuance of a Certificate of Occupancy. Signature of Applicant Date
All roof coverings to be Class` `'or better
Owner or authorized agent D— aw
0 i0o l=>
4 CITE' OF CUPERTINO
ADDITION/REMODEL
CUPEkTINO PERMIT APPLICATION FORM
APN # n � Coo
Date:
Building Address: 014 .
Mailing Address (if different from building address):
Owner's Name: Sg 1 .0 SO D�►�') Phone# : 40§ 91� r04
Contractor: � � Phone#:
Fax #:
Contractor License #:
Cupertino Business License #:
Contact: S D V-Ag_ s0 D tFM Phone#: +0 f 8 f 3 S6/4
Fax #:
.Building Permit Info: 2 W-kYdov l � ((tet'IT�'PM 4C"p '
Bldg. Elect. ® Plumb. Mech. MI Hillside ❑
Job Description:
Addition (adding sq footage):
A/0 N . S4-yitiC&y-t4 , akC.,1 ca_� M QG4a1k'C V k t p.,,b/it .
What is being remodeled (not including addition)?
lei I-(:�k C I )
Remodel Includes Re-Roof Yes. ❑ No If yes list number of squares
Remodel Includes Structural: Yes ❑ No
Do you have the pre-application planning approval? Yes ❑ No ❑
If yes,please provide a copy of your planning approval letter. Planners name:
Square Footage:
Addition: Porch: Deck: Garage: Detached Attached
Remodel: Kitchen '30 Bath 1 Z:�L- Other
Type of Construction (Usage Class): Occupancy Type:
1-A, 1-B ❑ II/IIIN-A ❑ II/III B, IV-HT, V-B 3
Valuation: 3 000 Please check this box if the project is a
second-story addition ElProject Size: ExpressStandard. ❑ Large ❑ Major F]
Please complete relevant portion of the Green Building
Checklist& attach it to the application or if applicable, Green Building Points Achieved: 0
include in plan set& the sheet index.
***For Office Use Only***
Over-the-Counter ❑ Revised 7/15/08
CITY OF CUPERTINO
4s4 e ADDITION/REMODEL.
fit..f
CUPE�TiNo FEE SCHEDULE
Quantity Fee ID Fee Description Fee Group Permit Type
Sq Ft
ADDITIONS 1R3SFDADD
PLLONGRNGR Long Range PL
Planning/Residential
1 R31NSP Dwellings Inspections B
1R3PLNCK Dwellings plan check B
1R3REPINSP Dwellings Repeat B
Inspection
1 R3REPPLNC Dwellings Repeat Plan B
Check
1R3HINSP Dwellings Hillside B
j inspection
1 R3HPLNCK Dwellings Hillside plan B
check
1R3HREINSP- Dwellings Hillside B
Repeat Inspection
1R3HREPLNC Dwellings Hillside B
Repeat Plan Check
lR3ALTINSP Dwellings Alternate B
Materials Inspection
1R3ALTPLNC Dwellings Alternate B
Materials Plan Check
i
1PCESS Cesspool P
1 PPRSEWG Ea. Private Sewage P
Disposal System.
1 PRSEWER Sewers P
j IBPSPRINK Lawn Sprinkler/Backflow P
IBPWSVCS Main Water Service P
1 BSEISMICRE SeismicResidential B
DECKS '1R3SFDADD OR
1R3SFD.REM
1DECKWOOD Deck (Wood)-Each B
I (Each)
1DECKRAIL . Deck Railing-Each B
(Each)
Community Development
�' 10300 Torre Avenue
r'd Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408) 777-3333
CUPEkTINO
Building Department
JOB ADDRESS: PERMIT #
/? C.J moTt, 11 961?01-r
OWNER'S NAME: Q l D N 9, SO D EM PHONE # S" Y 13-M4
GENERAL CONTRACTOR: T3D FAX #
I am not using any subcontractors:
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
N-� D g Z 3 0k
Owner/Contractor Signature Date