12120044CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS,�FvOREST AVE I CONSTRUCT ONAP AMERICAN I PERMIT NO: 12120044
I OWNER'S NAME: RAMALINGAM SUBRAMANI AND VENKATACHA 15632 VAN NUYS BLVD STE 367 1 DATE ISSUED: 07/30/2013 I
OWNER'S PHONE: 6508145368 IVAN NUYS, CA 91401 1 PHONE NO: (818) 301 -5354
❑ LICENSED CONTRACTOR'S DECLARATION
License Class CJ Lic. # �? 3
Contractor ,4 AA6$A jaa jq r-,,z Date —9
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.
APPLICANT CERTIFICATION
I certify that l 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. Addif ly, the applicant understands and will comply
with all non -point source re la ons per a Cupertino Municipal Code, Section
9.18.
Signature.
Date 7" 3o - 2,,o%
❑ OWNER- BUILDER DECLARATION
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:
1 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.
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
JOB DESCRIPTION: RESIDENTIAL u COMMERCIAL
CONVERSION OF ACCESSORY STRUCTURE TO A 640 SQ
FT
2ND LIVING UNIT (BATH 48 SQFT), (KITCHEN 80 SQFT)
& OTHER (512 SQFT) 41C7ea i" 0
Sq. Ft Floor Area: I Valuation: $30000
APN Number: 31623002.00 1 Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAvO FROM LAST CALLED INSPEECTION.
Issued by: Date: 7. ✓� '�3
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 of
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 Cuper ' o Municipal Code, Chapter 9.12 and
the Health & Safety Code, Sections 255 SL5533,,And 25534.
Date:
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
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Licensed Professional
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014 -3255
CUPERTINO (408) 777 -3228 • FAX (408) 777 -3333 • buildiintngCa�cupertino.org
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PROJECT ADDRESS JE
APN # 3 / 3 Q
OWNER NAME ? V i AM FiN I k' A r-/1 A I- I N( (n %l IN
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STREET ADDRESS
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CONTACT NAME
PHONE
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STREET ADDRESS
CITY, STATE, ZIP
FAX
❑ OWNER ❑ OWNER- BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME � c rz
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LICENSE NUMBER ," + 3 -
LICENSE TYPE
BUS. LIC #
COMPANYNAME
E -MAIL
FAX - (ip4 _� 1 2
A h AM C-- Y- A C AN 1- r,- J C. -I 10 AS
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STREET ADDRESS
CITY, STATE, ZIP
PHONE (� �� (I. _ �2 L
ARCHITECT/ENGINEER NAME
LICENSE NUMBER
BUS. LIC #
T1 q
COMPANY NAME
E -MAIL
FAX
STREET ADDRESS
CITY, STATE, ZIP
PHONE
DESCRIPTION OF WORK
(_0 r��1 +ICJ�.S1C NL't` A C — �y 7�vCTU)C Z= TC H 2 L k 4 Vll) ;r
EXISTING USE
PROPT�USE CONSTR.
TYPE
#STORIES
USE
TYPE
OCC.
SQ.FT.
VALUATION ($)
U 1
`;'^+ lj J�
�
EXISTG
AREA -
NEW FLOOR
AREA Ll
DEMO
AREA �`
TOTAL
NET AREA
256
BATHROOM
REMODEL AREA
KITCHEN
REMODEL AREA !�O
OTHER
REMODEL AREA
PORCH AREA
DECK AREA
TOTAL DECK/PORCH AREA
GARAGE AREA: DETACH
❑ ATTACH
# DWELLING Ufirr
IS A SECOND UNIT YES
BEING ADDED? ❑NO
SECOND STORY ❑YES
ADDITION? eNO
[J�U
I�\
PRE - APPLICATION ❑ YES IF YES, PROVIDE COPY OF
IS THE BLDG AN ❑ YES
RECEIVED BY:
T TAL VALUATION:
PLANNING APPL # []NO PLANNING APPROVAL LETTER
EICHLER HOME? EkNO
3 000
By my signature below, I certify to each of the folio g I am the property owner or authorized agent to act on the property owner's beh l£ I have read this
application and the information I have provided is 9&Q. 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 co t n. .1 authorize representatives of Cupertino to enter the above - identified property for inspection purposes.
Signature of Applicant/Agent: Date: Zff d 12,
SUPPLEMENTAL INFORMATION REQUIRED
PLAN CHECKTYPE
ROUTING SLIP
❑ oVER -THE COUNTER
❑ 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 ofthis project.
❑ LARGE -
❑ FIRE DEPT
_ Copy of Planning Approval Letter or Meeting with Planning prior to
❑'
❑
submittal of Building Permit application.
MAJOR
SANITARY SEWER DISTRICT
❑ ENVIRONMENTAL HEALTH
BldgApp_2011.doc revised 06121111
FEW CITY OF CUPERTINO
Jm# FEE ESTIMATOR — BUILDING DIVISION
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NOTE. This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School
Dietrirt otr_ ) _ Thaco foot aro hacod an tho nroliminary inlarmatian availahlo and aro only an ovdmaty_ Cantart tho Dent for addn'1 info.
FEE ITEMS (Fee Resolution 11 -053 YL 7/1/12)
$ Forest Ave.
DATE: 12/10/2012
REVIEWED BY: jsg
JimADDRESS:
APN:
BP #:
'VALUATION: 1$30,000
*PERMIT TYPE: Building Permit
PLAN CHECK TYPE: Addition
PRIMARY SFD or Duplex
USE:
Suppl. PC Fee: Q Reg. Q OT
PENTAMATION 1 R3SFDREM
PERMIT TYPE:
wORK I
Conversion of accessory structure to a 2nd living unit
SCOPE
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NOTE. This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School
Dietrirt otr_ ) _ Thaco foot aro hacod an tho nroliminary inlarmatian availahlo and aro only an ovdmaty_ Cantart tho Dent for addn'1 info.
FEE ITEMS (Fee Resolution 11 -053 YL 7/1/12)
FEE
QTY /FEE
MISC ITEMS
Plan Check Fee:
$0.00
DTI s.f.
$600.00
Remodel, Bath (< =300 sf)
IREMRESBAT
Suppl. PC Fee: Q Reg. Q OT
0,0
hrs
$0.00
PME Plan Check:
$0.00
80 s.f.
$600.00
Remodel, Kitchen (< =300 sf)
IREMRESKIT
Permit Fee:
$0.00
Suppl. Insp. Fee-.0 Reg. Q OT
0.01
hrs
$0.00
= s.f. Remodel, Other
$467.00 IREMRESOTH
PME Unit Fee:
$0.00
PME Permit Fee:
$0.00
Construction Tax: IBCONSTAXR
1
# 11ew
units
$629.29
Arrmurt,ctr "[rtll`c' 1'c'�'_
E)
Work Without Permit? 0 Yes 0 No
$0.00
Advanced Planning Fee:
$0.00
Select a Non - Residential
Building or Structure
0
i
T� urc�l Dof.�rrn�<rnfuti «rr I�`eE.�`
Strong Motion Fee: IBSEISMICR
$3.00
Select an Administrative Item
C�
12-1
Bldg Stds Commission Fee: IBCBSC
$2.00
SUBTOTALS;
$634.29
$1,667.00
11, TOTAL 01.29
Revised: 10/01/2012
CUPERTINO
Building Department
CITY OF CUPERTINO
10300 TORRE AVENUE • CUPERTINO, CA 95014 -3255
TELEPHONE: (408) 777 -3228 • FAX: (408) 777 -7606
OFFICIAL NOTIFICATION OF NEW /ADDRESS CHANGE
TO: All Agencies
FROM: City of Cupertino
DATE: June 05, 2014
RE: New /Change of Address APN #316 -23 -002
Please note the following new address: 20118 Forest is adding a new 2nd unit. The main
house will remain 20118 Forest Ave and the 2nd unit will be 20120 Forest Ave. See
attached map.
The new address will take effect 30 days from the date of this letter. Please update your
records accordingly. If you have any questions, please call me at (408) 777 -3246.
Sincerely,
Susan Winslow
Administrative Clerk
Cupertino Building Dept
408 - 777 -3246 or suew @cupertino.org
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