B-2016-2937From
To
Date: t �VVI
��"1,7
Senthil Palanisamy
10221, Vicksburg Dr, Cupertino, CA 95014
Community Development Department - Building Division,
10300 Torre Ave, Cupertino, CA 95014-3255
Sub: Request for cancellation of building permit # B-2016-2937
(datedl0-18-2016)
Hi,
I have obtained the owner -buil(
stucco of the front facing side o:
2016-2937. I haven't started th
near future. So, I request this p
returned to me.
Thank you!
Rgds
Ir-
Senthil Palanisamy
10221 Vicksburg Dr,
Cupertino, CA -95014
408-839-4580
I CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS:
10221 VICKSBURG DR CUPERTINO, CA 95014-3358 (369 07 010)
OWNER'S NAME: PALANISAMY SENTHIL K AND SAMBASIVAM MEENAKS
OWNER'S PHONE: 408-839-4580
LICENSED CONTRACTOR'S DECLARATION
License Class Lic. #
Contractor HOMEOWNER/BUILDER Date
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 prope or
inspection purposes. (We) agree to save indemnify and keep harml s the
City of Cupertino against liabilities, judgments, costs, and expenswhi
may accrue against said City in consequence of the granting of is pe it.
Additionally, the applicant understands and will comply with al on-poit
source regulations per the Cupertino Municipal Code, Secti 9.18.
I hereby affirm that I am exempt from the
following two reasons:
1. I, as owner of the property, or my
compensation, will do the work. A
I
ale (Sec.7044, Business &
%i.I, as owner of the property,
contractors to construct th>r
License Law for one of the
iployees with wages as their sole
the structure is not intended or offered for
CONTRACTOR: I PERMIT NO: B-2016-2937
DATE ISSUED: 10/1
PHONE NO:
[TII.DING PERNIIT INFO:
BLDG _ ELECT _ P
MECH X RESIDEN CO CL4L
?STUCCORO TI STO0
RYHO(70 S. ,)
�Sq. Ft Floor Area:t do . $4000.00
II \ t�
"N Numccupancy Type: " \
369 07 01.11 . 1
a%4T EXPIRES IF WORK IS NOT STARTED
CHIN 180 DAYS OF PERMIT ISSUANCE OR
DAYS FROM LAST CALLED INSPECTION.
Issued by: Abl2y Aysndg
Date: 10/18/2016
RF ROOFS:
All roofs shall be inspected prior to any roofing material being installed. If a roof is
installed without fust obtaining an inspection, I agree to remove all new materials for
inspection.
1'essions Code)
exclusively contracting with licensed Signature of Applicant:
ject (Sec.7044, Business & Professions Code). Date: 10/18/2016
hereby affirm under penalty (perjury one of the following three declarations:
1. I have and will mainjAin a Certificate of Consent to self -insure for Worker's
Compensation, as govided for by Section 3700 of the Labor Code, for the
,,performance of -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.
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 10/18/2016
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
HAZARDOUS h•ATERIALS 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 Cod Chapter 9.12 and
the Health & Safety Code, Sections 05, 25533, 5534.
O"er or authorized agent:
Date: 10/18/2016
CONSTRUCTION LENDINGAGENCY
1 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
•vCHET CI D>±CI.ARATION
I understand my plans shall be used as public records.
Licensed
Professional
PERMIT FEE RECEIPT
Case # B-2016-2937
Date Printed: 04/05/2017
CUPERTINO
CITY OF CUPERTINO - FEES RECEIPT
Case Number: B-2016-2937 Permit No: B-2016-2937
Project Valuation: 4000.00 Date Submitted: 10/18/2016
Permit Type: Building
Address/APN: 10221 VICKSBURG DR CUPERTINO, CA 95014-3358 (369 07 010)
Scope of Work: RESTUCCO ONE STORY HOME (700 S.F.)
Contact Type: Applicant
Full Name: PALANISAMY SENTHIL K AND SAMBASIVAM P
Address: 10221 VICKSBURG DR CUPERTINO, CA 95014
Email: Cupertino_eplans@cupertino.org
Contact Type: Property Owner
Full Name: PALANISAMY SENTHIL K AND SAMBASIVAM t
Address: 10221 VICKSBURG DR CUPERTINO, CA 95014
Bldg Stds Commission Fee
Restucco Fee
Strong Motion Category 1
Bldg Stds Commission Fee
10/18/2016
SENTHIL PALANISAMY
Strong Motion Category 1
10/18/2016
SENTHIL PALANISAMY
Restucco Fee
10/18/2016
SENTHIL PALANISAMY
`alb
ccM�uQAL, A�,?�
04/05/2017 - 2:27:51 PM - Generated by: patriciag
Credit Card
Credit Card
Credit Card
FEE TOTAL
AMOUNT PAID
BALANCE DUE
$1.00
$370.00
$0.52
f) $1.00 l n1
U $0.52
$370.00
$371.52
$371.52
$0.00
/1
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS:
10221 VICKSBURG DR CUPERTINO, CA 95014-3358 (369 07 010)
OWNER'S NAME: PALANISAMY SENTHIL K AND SAMBASIVAM NEENAKS
OWNER'S PHONE: 408-839-4580
LICENSED CONTRACTOR'S DECLARATION
License Class Lic. #
Contractor HOMEOWNER/BUILDER Date
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.
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.
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 10/18/2016
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of the
following two reasons:
1. 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:
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
0_
' 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. n ---7n
iature a-- / Date 10/18/2016
CONTRACTOR: I PERMIT NO: B-2016-2937
HOMEOWNER/BUILD
ER
DATE ISSUED: 10/18/2016
PHONE NO:
BUILDING PERMIT INFO:
X BLDG _ ELECT _ PLUMB
_ MECH X RESIDENTIAL _ COMMERCIAL
JOB DESCRIPTION:
RESTUCCO ONE STORY HOME (700 S.F.)
Ft Floor Area: I Valuation: $4000.00
APN Number: Occupancy Type:
369 07 010
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
by: Abby Ayende
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 ofAppl
Date: 10/18/2016
11 A 11
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. 1 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 Cod Chapter 9.12 and
the Health & Safety Code, Sections 05, 25533,0 5534.
1-1 7
,.
Owner or authorized agent:
Date: 10/18/2016
CONSTRUCTION LENMG 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
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE CUPERTINO, CA 95014-3255
CUPERTINO (40{8 ((
)777-3228 -FAX 408) 777-3333 • buildEiing(&cuperfino.ora
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OWNERNAME JCC/ , T*l L Pft -,W/S F l M Y
PHONE 4 CJ ^?,Y..3 9 `t 5-, ?o
E-MAILS6NTf/ 11, P y L c! In A
-STREET ADDRESS1022-1 � %/ C 1 ( �
CITY, STATE, ZIPO p ysSP { j
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FAX
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STREET ADDRESS/0.2—yl
CITY, STATE, ZIP (/ P tl%27eve? CA 76f4:
FAX
❑ OWNER VOWNER.BUILDER 13 OWNER AGENT 13 CONTRACTOR ❑ CONTRACTOR AGENT 0 ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME
LICENSE NUMBER
LICENSE TYPE
BUS. LIC #
COMPANY NAME
E—MAIL
FAX
STREET ADDRESS
CITY, STATE, ZIP
PHONE
ARCHITECUENGINHER NAME.
LICENSE NUMBER
BUS. LIC #
COMPANY NAME
E-MAIL
FAX
STREET ADDRESS
CITY, STATE, ZIP
PONE
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DESCRIPTION OF WORK % r f
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EXISTING USE
PRO SED USE CONSTR.
TYPE
# STORIES
_ -
-
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USE
TYPE
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SQ.FT.
VALUATION ($):
EXISTG
NEW FLOOR'.
DEMO -
TOTAL
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AREA
AREA..
NET AREA
-
BATHROOM
KITCHEN
OTHER
- -
REMODELAREA
REMODELAREA_,
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PORCHAREA
DECK AREA
TOTAL DECK/PORCH AREA
-
GARAGE AREA: - DETACH
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ATTACH
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#DWELLINGUNITS:
LSASECONDUNIT ❑YES
'SECONDSTORY 13YES
BEINGADDED? '❑NO
ADDITION? [)NO
PRE -APPLICATION ❑ YES. IF YES, PROVIDE COPY OF
IS THE BLDG AN ❑ YES
REOEIVEDBY-
TOTAL VALUATION[
PLANNINGAPPL# ®NO PLANNING APPROVAL LETTER
EICHLERHOMET ❑.NO:
By my signature below, I certify to each of the following: I am the property owner or authorized agent tolact 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 auth ' epresentatives:of Cupertino to enter the above -identified property for inspection purposes.
Signature of ApplicantlAgent: Date: 1--r)'f
SUPPLEMENTAL INFORMA QUIRED
PLAN CHECK TYPE
ROUTING SLIP
[] OVER-THE-COUNTER
sllu nHvoPa aN REvaEw
New SFD or Multifamily dwellings: Apply for demolition permit for
eXisting.building(s). Demolition permit is required prior to issuance of building
"
�Y,LANNIiGPLANREvllc\ Akke
permit for new building.
Q EXPRESS
-
Commercial Bldgs: Provide a completed Hazardous Materials Disclosure
❑ STANDARD
0 PuEtwWom
form if any Hazardous Materials are being used as part of this project..
0 ,. LARGE
0 FMDTIPT
_ Copy of Planning Approval Letter or Meeting with Planning prior to
0 MAJOR
0 SANITARY SEWER DISTRICT
Submittal of Building Permit application.
Q ENVIRONMENTAL HEALTH
BldgApp_2011.docrevised 06121/11
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OWNER -BUILDER DISCLOSURE FORM
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE,- CUPERTINO, CA 05014-3255
CUPERTINO (408) 777-3228 • FAX (408)777-3333 buildingx5cunertino.orn
Dear Property Owner(s) -
An application for a building permit has been submitted in your name listing yourself as the builder of the property
improvements specified at:
r�
SITE ADDRESS 02-2 / ,vi c 'p j U (j reCk Pde—
APN
BP#' '
OWNER NAMES,�T 9/S21
OWNER ADDRESS 62 , y d p 'tLf%e-A?J
DESCRIPTION OF WORK ` r
A✓��
We are providing you with an Owner -Builder Acknowledgment and Information Verification Form to make you aware of
your responsibilities and possible risk you may incur by having this'permit issued in your name as the Owner -Builder. We
will not issue a building permit until you have -read, initialed your understanding of each provision, signed, and
returned this form to us at our official address indicated. An agent of the owner cannot execute this notice unless
you, the property owner, obtain the prior approval of the permitting authority.
OWNER'S ACKNOWLEDGMENT AND VERIFICATION OF INFORMATION
(DIRECTIONS. Please read and initial each statement below to signify you understand or verify this information.)
le. I understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner-
uidelr" building permit that erroneously Implies that the property owner is providing his or her own labor and material
personally. 1, as an Owner -Builder, may be held liable and subject to serious financial risk for any injuries sustained by
an :unlicensed person and :his or her employees while working on my property. My homeowner's insurance may not
provide coverage for those -injuries. I am willfully acting as an Owner-Builderand am aware of :the limits of my
insurance coverage for injuries to workers on my property.
understand building permits are not required to be signed by property owners unless they are responsible for
the construction and are not hiring a licensed Contractor to assume this responsibility.
F
. I understand as an "`Owner -Builder" I am the responsible party of record'on the permit. t understand that I may
t myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her
name instead of, my own.
4. I understand Contractors are required by to be licensed and bonded in California and to list their license
umbers on permits and contracts.
. 1 understand if I ;employ or otherwise engage any persons, other than California licensed Contractors, and the
5 e
total value of my construction is at least five hundred dollars ($500), including labor and materials, I may be
considered' an "employer" under state and federal law.
6. 1 understand if I am considered an "employer" under state and federal law, 1 must register with the state and
federal government, withhold payroll taxes, provide workers' compensation disability insurance, and contribute to
unemployment compensation for each "employee." I also understand my failure to abide by these laws may subject
me to serious financial risk.
7. I understand under California Contractors' State License Law, an Owner -Builder who builds single-family
residential structures cannot legally build them with the intent to offer them for sale, unless all work is performed by
licensed subcontractors and the number of structures does not exceed fourwithin any calendar year, or all of the work
is performed under contract with a licensed general building Contractor.
�?_8. 1 understandas an Owner -Builder if I sell the property for which this permit is issued, I may be held liable for
any financial or personal injuries sustained by any subsequent owner(s) that result from any latent construction
defects in the workmanship or materials.
6wnerBuilderForfn 2010.doc revised 04114110
9.1 understand I may obtain more information regarding my obligations as an "employer" from the Internal
Revenue Service, the United States Small Business Administration, the California Department of Benefit Payments,
and the California Division of Industrial Accidents. I also understand I may contact the California Contractors' State
License Board (CSLB) at 1-800=321-CSLB (2752) or www.esib.ca.gov for more information about licensed
contractors.
10. 1 am aware of and consent to an Owner -Builder building permit applied for in my name, and understand that I
am aparty legally and financially responsible for proposed construction activity at the site address listed above.
11,1 agree that, as the party legally and financially responsible for this proposed construction activity, 1 will abide
by all applicable laws and requirements that govern Owner -Builders as well as employers.
012. 1 agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the
information 1 have provided on this form. Licensed contractors are regulated by laws designed to protect the public. If
you contract with someone who does not have a license,, the Contractors' State License Board may be unable to
assist you with any financial loss you may sustain as a result of a complaint. Your only remedy against unlicensed'
Contractors may be in civil court. It is also important for you to understand that if an unlicensed Contractor or
employee of that individual or firm is injured while working on your property, you may be held liable for damages. If
you obtain a permit as Owner -Builder and wish to hire Contractors, you will be responsible for verifying whether or not
those Contractors are properly licensed and the status of their workers' compensation insurance coverage.
CONSTRUCTION LENDING AGENCY
(DIRECTIONS: Please complete the following construction lending agency, information.)
hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued
(See 3097 Civ.)
Lender Name: Lender Address:
Before a building permit can be issued, this form must be completed and signed by the property owner.and
returned to the agency responsible for issuing the permit. Note: A copy of the property owner's driver's license,
form notarization, or other verification acceptable to the city m y be required to be presented when the permit is issued
to verifythe roe owner's signature.
Property Owner's Signature: 1Z Date/01 W1294
(NOTE: The following Authorization Form is required to be completed by the property owner only when designating an
agent of the property owner to apply for a construction permit for the Owner -Builder).
AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF
Excluding the Notice to Property Owner, the execution of which 1 understand is my personal responsibility, 1 hereby
authorize the following person(s) to act as my agent(s) to apply for, sign, and file the documents necessary to obtain an
Owner -Builder Permit for my project.
Scope of Construction Project (or Description of Work):
Project Location or Address:
Name of Authorized Agent:
Address of Authorized Agent:
Tel No
1 declare under penalty of perjury that 1 am the property owner for the address listed above and 1 personally filled out the
above information and certify its accuracy. Note: A copy of the property owner's driver's license, form notarization, or other
verification acceptable to the city may be requiredto be presented when the permit is issued to verify the property owner's
signature.
Property Owner's Signature: - Date:
OwnerBuilderForm 2010.doc revised 04114110
CUPERTINO
CONTRACTOR / SUBCONTRACTOR LST
Building Department
City Of Cupertino
10300 Torre Avenue
Cupertino, CA 95014-3255
Telephone: 408-777-3228
1 Fax: 408-777-3333
JOB ADDRESS: Ilj2,_2j jj6:&,
, �V, a 1Z
PERMIT
OVINER'S NAME: ,g'.,z-rf
7
PHONE#
GENERAL CONTRACTOR:
BUSINESS LICENSE #
ADDRESS:
CITY/ZIPCODE:
ur municipal coue requires all businesses working in the city to have a -City of Cupertino business license.
NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE
GENERAL CONTRACTOR AND ALL SUBCONTRACTORS VE OBTAINED A CITY OF CUPERTINO
BUSINESS LICENSE.
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following information:
6/
SUBCONTRACTOR
BUSINESS NAME
BUSINESS LICENSE #
Cabinets & Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring / Carpeting
Linoleum / Wood
Glass / Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Painting Wallpaper -
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner / Contractor Signature Date