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14010053 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 21516 MONROVIA ST CONTRACTOR:RAGHAVA DENDULURI PERMIT NO:14010053 OWNER'S NAME: RAGHAVA DENDULURI 21516 MONROVIA ST DATE ISSUED:01/072014 OWNER'S PHONE: 4087170123 CUPERTINO,CA 95014-4804 PHONE NO: ❑ LICENSED CONTRACT R'S DECLARATION JOB DESCRIPTION:RESIDENTIAL COMMERCIAL ADD 50 S.F.TO REAR PROPERTY TO REMOVE(E) License Class Lic.# BATHROOM IN ORDER TO ENLARGE(E)LAUNDRY AREA Contractor Date I hereby affirm that I RM 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 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. Sq.Ft Floor Area: Valuation:$12000 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 APN Number:35623021.00 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 D YS F T LLED 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 granting of this permit. Additionally,the applicant understands and will comply Is y: Date. withal]non-point source regulations per the Cupertino Municipal Code,Seetion 9.18. RE-ROOFS: Signature Date 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. OWNER-BUILDER 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 ROOT:COVERINGS TO BE CLASS"A"OR BETTER 1,as owner of the property,or my employees with wages as their sole compensation, will do the work,and the structnre is not intended or offered for sale(Sec.7044, Business&Professions Code) as owner of the property,am exelusively 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. I 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(a)should I stare 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 ofthe Labor Code,for the air contaminants as defined by the Bay Area Air Quality Management District I performance of the work for which this permit is issued. will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sections 2550 25 nd 25534. Section 3700 of the Labor Code,for the performance of the work for which this 1}_ 1110, permit is issued. Owner or authorized agent:_ �%Dat I certify that in the performance of the work for whieh 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 Califomia. 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 shall be deemed revoked. work's for which this permit is issued(See.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 indemnify and keep harmless the City of Cupertino against liabilities,judgments, ARCHITECT'S DECLARATION costs,and expenses which may accrue against said City in consequence of the i understand my plans shall be used as public records. granting of this permit.Additionally,the applicant understands and will comply with all non-point source reguldo per the Cupertino Municipal Code,Section Licensed Professional 9.18. L61wd1 } 5 ,y • Signature Date LaCONSTRUCTION PERMIT APPLICATION COMMUNETY'DEVELOPMENT DEPARTMENT• BUILDING DIVISION D� 10300 TORRE AVENUE•CUPERTINO,CA 95014-3255 CUPERTINO' (408)777-3228- FAX(408)777-3333•build in-g0-cupertino,ora ❑NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION I TI ❑ REVISION I DEFERRED ORIGINAL PERMIT# PROJECT ADDRESSAPN N . ^ (�OWNERNAMP h W J9L PHONE HONE . 40 p t7 1 E-MAIL f A(J kfvve 0,24) -1 STREET ADDRESS N114(94.00A sT m' An f)0 FAX CONTACT NAME RA `Y 1 y�� �P v �9_f) PHONE Gt o g `717 D)43 EMAIL STREET ADDRESS /� / CITY,STATE,ZJP , FAX 'OWNER ❑ OWNER-BUni)LR ❑ OWNERAGENI ❑ CONTRACTOR ❑CONIRACTORAGENr ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT CONTRACTORNAME Q LICENSENUMBER TTC;SETYPE BUS,LIC6 COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE ARCHI ECT1ENOINEER NAME , Tit/ .0 ns LICENSE NUMBER O Bus.LIC 0 COMPANYNAME [ 1 U"V 6-�Ary f'1 ESL FAX V 3TC on I "S f LYY} STREET ADDRESS CITY,STATPHONE 5"o Can f csu hl� <.O DESCRIPTION OF WORK ;r.o SQ 69F ,op mtrin EXISTING USE PROPOSED USE CONSTR TYPE N STORIES �1 �� I V, ����+ V-L5 USE �T/YPE OCC. SQ.F C. VALUATION($) AREAE�isTL REA 7R AREA .N 1/ TOTAL A 9033 i �7 - -3 iq� 7-0.73 vo is Iry BATHROOM KITCHEN OTHER L REMODEL AREA REMODEL AREA REMODEL AREA PORCH AREA 1 111 11110PORCHAKEA I GARAGE AREA: DErACH []ATTACH #DWE GUNITS: ISAsECOND ri' ❑YES SECONDSTORY DYES BEINGADDED' []NO ADDMON! []NO PRE-APPLICATION ❑YES W YES,PROVIDE COPY OF IS THE BLDG AN ❑YES VALUATION: PIANNWGAPPL9 ONO PLANNING APPROVAL LETTER EICIII.ERHOME! ❑NO � - - _ 12: �+v By my signature below,I certify to each of the following: I am the property owner or authorized agent to act o ~owner's behalf. I have read this application and the information I have provided istcorrrct. 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 con o I authorize representatives of Cupertino to enter the above-identified property for inspection purposes. Signature of Applicant/Agent: Date: d( `ZO SUPPLEMENTAL INFOkMATION REQUIRED PTYPE__-_ ROUTING'SLIP_ _New SFD or Multifamily dwellings: Apply-foe demolition permit for t Q 'ovER-THE eturiERg ❑S'•EUILDINGPLAN REVIESv existing building(s). Demolition permit is required prior to issuance of building x permit for new building.' ` 4E EI[PRESs ❑-PLANNING PLA REVIEW _Commercial Bldgs: Provide a completed Hazardous Materials Diselosure ❑ STANDARD © PUBLIC'AORKS r 7 r form if any Hazardous Materials are being used as part of this project. _❑ i ARCS`; ❑;FIItE Dxsr'� 5` k v '' _Copy of Planning Approval Letter or Meeting'with•Planning prior to 0 MAJo� D SANITARY SEWER pI5TR1CT submittal of Building Permit application. ❑'ENVIRONMENTAL HEALTH_ B1dgAFp_2011.doc revised 06121111 CITY OF CUPERTINO FEE ESTIMATOR-BUILDING DIVISION ADDRESS: 21516 MONROVIA ST DATE: 01/07/2014 REVIEWED BY: MELISSA APN: 356 23 021 BP#: M01005:3 'VALUATION: 1$12,000 PERMIT TYPE: Building Permit PLAN CHECK TYPE: Addition PRIMARY 2nd Unit? Yes • No PENTAMATION 5�D or Duplex OTC? ®Yes 1 R3SFDADD USE: ®No PERMIT TYPE: A WORK ADD 50 S.F. TO REAR PROPERTY TO REMOVE E BATHROOM IN ORDER TO ENLARGE E SCOPE LAUNDRY AREA OCCUPANCY TYPE: TYPE OF FLR AREA PC FEES PC FEE ID BP FEES BP FEE ID CONSTR. s.f. R-3 (Custom) II-B,ul-s,iv,V-B 50 $1,059.00 1,4DDPLCK $1,026.00 IRDDINSP TOTALS: 50 1 $1,059.00 $1,026.00 MECH,HOURLY O Yes O No PLUMB,HOURLY Yes Q No ELEC,HOURLY O Yes Q No Nlech. flan Check Plumb. Plan Check Elec.Plan Check 7111-11.permit Fee: Plumb,Permit Fee: Elect.Pennir f ee.- Other h9ech.Insp. Other Plumb Imp, Ll Orher Elec.Insp. Mech.hup.Fire: Plumb, Insp.Fee., Elect.hup.Fee: NOTE:This estimate does not include fees due to outer Departments(i.e.Planning,Public Works,Fire,Sanitary Sewer District,School District ett^). Thesefees are based on lite prefimina information available and are only an esti»:ate. Contact lite De t or addn'1 info. FEE ITEMS Le Resolution 11-053 Eff 711113) FEE QTY/FEE MISC ITEMS Plan Check Fee: $1,059.00 Select a Misc Bldg/Structure Suppl.PC Fee: (D Reg. O OT 0,0 hrs $0.00 or Element of a Building PME Plan Check: $0.00 Permit Fee: $1,026.00 Suppl. Insp.Fee:Q Reg. Q OT 0,0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 Construction Tax: .4dininistrative Fee: Q Work Without Permit? (3 Yes (D No $0.00 G Advanced Planning Fee: IPLLONGR $7.00 Select a Non-Residential E) Travel Documentation Fees: Building or Structure O Strong Motion Fee: IBSEISMICR $1.20 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $1.00 SUBTOTALS: $2,094.20 $0.00 TOTAL FEE: 1 $2,094.20 Revised: 01/01/2014 Building Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014-3255 Telephone: 408-777-3228 C U P E RT[N O Fax:408-777-3333 CONTRACTOR/SUBCONTRACTOR LIST JOB ADDRESS: 21St b N0fVPWV1 5T CWPtf-Tlr Q PERMIT# O/00-5-- 34 OWNER'S NAME: KA67HAA bt-N7UL-UM PHONE# O 1 Z3 GENERAL CONTRACTOR: BUSINESS LICENSE# ADDRESS: CITY/ZIPCODE: *Our municipal code 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 HAVE OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE. I am not using any subcontractors: Signature Date Please check applicable subcontractors and complete the following information: SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets & MilIwork 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 Owuer Contractor Signature bate r' OWNER-BUILDER DISCLOSURE FORM ¢ COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION 10300 TORRE AVENUE• CUPERTINO,CA 95014-3255 CU+PERTINO (408)777-322B• FAX(408)777-3333 buildin4(ab-Cuoertino.org 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: op"TIDDRESS APN BP# al 0 b An ONKOVI sT cV &P_r � s 3 OMER NAMZ OWNER ADDRESS VA E V L Ro !A CU EP—r J nS p ESCRIPTION OF WORK: 111 blq $ M A-5TC—_ &_-;fl � VAL_ DF lr A7 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.) I understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner- 1 der"building permit that erroneously implies that the property owner is providing his or her own labor and material T. onally. I,as an Owner-Builder, may be held liable and subject to serious financial risk for any injuries sustained by • ' nlicensed person and his or her employees while working on my property. My homeowner's insurance may not re ide coverage for those injuries. I am willfully acting as an Owner-Builder and am aware of the limits of my i s rance coverage for injuries to workers on my property. . I understand building permits are not required to be signed by property owners unless they are responsible for -,. onstruction and are not hiring a licensed Contractor to assume this responsibility. 3. 1 understand as an"Owner-Builder" I am the responsible party of record on the permit. I understand that I may rotzet myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her e instead of my own. 4. I understand Contractors are required by law to be licensed and bonded in California and to list their license rbers on permits and contracts. 5. I understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the 0 N value of my construction is at least five hundred dollars ($500), including labor and materials, I may be osldered an "employer„under state and federal law. Q I understand if I am considered an "employer" under state and federal law, I must register with the state and f .deral government, withhold payroll taxes, provide workers' compensation disability insurance, and contribute to u employment compensation for each "employee." I also understand my failure to abide by these laws may subject .:o serious financial risk. . I understand under California Contractors' State License Law, an Owner-Builderwho builds single-family 18britial structures cannot legally build them with the intent to offer them for sale, unless all work is performed by lic used subcontractors and the number of structures does not exceed four within any calendar year, or all of the work is 'erformed under contract with a licensed general building Contractor. .er$, I understand as an Owner-Builder if I sell the property for which this permit is issued, I may be held liable for any Inanciai or personal injuries sustained by any subsequent owner(s)that result from any latent construction def in the workmanship or materials. Ol+rrerBiiilderFo77:i 2010.docrevised04/14/10 9. 1 understand 1 may obtain more information regarding my obligations as an "employer"from the Internal enue Service,the United States Small Business Administration, the California Department of Benefit Payments, an the California Division of Industrial Accidents. I also understand I may contact the California Contractors' State IG nse Board (CSLB) at 1-800-321-CSLB (2752) or www.cslb.ca.gov for more information about licensed bc�tractors, . 10. 1 am aware of and consent to an Owner-Builder building permit applied for in my name, and understand that I i''the party 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, I will abide f3yfall applicable laws and requirements that govern Owner-Builders as well as employers. �V7,11 1 agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the ion I 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.) 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.) 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 notarizatlon, or other verification acceptable to the city may be required to be presented when the permit is issued to verify the property owner's signature. Property Owner's Signature: r date: © a�, r -------------------------------------------------------------------------------------------------------------------------------------- - (NOTE. The following Authorization Form is required to be completed by the property owner only when designating--a-n--- agent of the property owner to apply for a construction permit for the Owner-Builder). AUTHORIZATION OF AGENT TO ACTON PROPERTY OWNER'S BEHALF Excluding the Notice to Property Owner,the execution of which I understand is my personal responsibility, I 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- Tel No Address of Authorized Agent: declare under penalty of perjury that I am the property owner for the address listed above and I 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 required to be presented when the permit is issued to verify the property owner's signature. Property Owner's Signature: Date: OwnerBuilderForm 7010.doe revised 04/14/10