11120073OWNER'SBUILDING ADDRESS4
a 10815 BROOKWELL DR
1 t 4086566364
Contractor Date
I hereby affirm that I am licensed under the provisions of Chapter 9
(CORHOCROlig With Section t, i Division r Business
r
[ hereby affie•€€► under penalty of perjury one of the folloaviug hvo declarations:
€ have and will maintain a certificate of consent to self4nsure for Worker's
Compensation, as provided for by Section 3700 of die Labor Code, for the
performance of the work for which this permit is issued.
€ 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 tris
permit is issued.
APPLICANT CERTIFICATION
t certify that I have read this application and state that the above information is
correct I agree to comply with all city and county ord€nances and state laves 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 tine Cupertino Municipal Code, Section
I hereby affirmaffirmkhat I aamexempt from flue Contractor's Lncense Lasv for one of
the fo[Eow[ng hs'o reasons:
[, 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)
1, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec.7044, Business & Professions Code).
I hereby affirm sunder penaltpenalty
of perjuery one of the following three
cleclarat[o€ns:
I have and will maintain a Certificate of Consent to selfinsure for Worker's
Compensation, as provided for by Section 3700 of the Labor Code, for the
performance of the work for which tis permit is issued.
t have and wi€t 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 OwE
forthwith comply with such provisions or this permit shall be deemed revoked.
MIL
[certify that I (nave read tlhis application and state that [he above information is
correct. 1 agree to comply with aEl city and county ordanances and state laws relating
to building constnection, and hereby authorize representatives of this city to ehnter
upon the above mentioned property for inspection proposes. (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 Ntunicipal Code, Section
9.13.
Signature Date
CON TRACTOR:KRISHNAN
MUSARAVAKKAM S
, cA 95olt�l6oa
PERIIIIT NO: 11120073
DATE ISSUED: 02/01/2012
PHONE NO:
BUILDING PERMITIT INFO: BLDG I ELECT ( PLUMB )_._
MECH j« RESIDENTIAL COMCOMMERCIAL
JOB DESCRIPTION: REI\40VE AND REPLACE PATIO COVER, REI4iOBEL
BATHROONI(I00SQFT), NO ELECTRICAL OR LIGHTING
sq. Ft Flo®r Area:
APN Number: 36921019.00
Valuation: $6000
Occupancy Type:
Issued br�•'""Jf�> Date:
RE -ROOFS:
AEl roofs shall be inspected prior to :uny roofnng material being installed. If a roof is
installed without first obtaining an remove all new materials for
inspection.
Signature of
Date:
Ii 111f1Z�7i7T�711901{71►CtI►�f C/�JI��F_T.Yi.7[i:ZI[IIIisT,lll f111Dit�
tI�Y�1:i 1Iili7v��� �y IIDi:i F 7[L'� t7 I.� I[I7.'III RDI
I Leave read the hazardous €materials requirehments under Chapter 6.95 of tlhe
California Health &Safety Code, Sections 25505, 25533, and
Ch
25534. i evi[1 maintain
compliance with the Cupertino Municipal Code, apter 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 c►uit hazardous air
contaminants as defined by the Bay Area Air Quality Management District I will
it compliance with the Cupertino Municipal Code, Chapter 9.12 and the
Health & Safety Code, Sections 25505, 25533, and 25531.
�J ththoh•ized at:
li"t �.%a� 3 � Date:__c���.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agehncy for the performance of vwrk's
for which tins permit is issued (Sec. 3097,
Lender's Name
Lender's AAddress
I understa€nd my plans slhali be used as public records.
Licensed
CITY OF CUPERTINO
FEE ESTIMATOR — BUILDING DIVISION
ADDRESS: 10815 brookwell dr.
DATE: 12/08/2011
REVIEWED BY: bobs.
Ila APN: f2b 2 ,
B P #: -Z
*VALUATION: 1$6,000
*PERMIT TYPE: Building Permit
s.f.
$588.001
PLAN CHECK TYPE:
Alteration / Repair
PRIMARY SFD or Duplex
USE:
I-0-.0-1
hrs
PENTAMATION 1R3SFDRE
I PERMIT TYPE:
WORK
and replace patio cover, remodel bathroom= no electrical or lighting.
SCOPE
[��e
Permit Fee:
$0.00
NOTE: This estimate does not includefees due to offier Departments (i. a Planning, Public Works, Fire, Sanitary Sewer District, School
District, eta). These fees are based on the Preliminary information available and are on/v an estimate. Contact the Dent for addn'l info.
FEE ITEMS (Fee Resohition 11-053 Aff Z��l
FEE
QTY/FEE
I MISC ITEMS
Plan Check Fee:
$0.00
s.f.
$588.001
Remodel, Bath (<=300 sf)
IREAMESBAT
Suppl. PC Fee: (j) Reg. 0 OT
I-0-.0-1
hrs
$0.00
PME Plan Check:
$0.00
= # Covered Porch
$914.0011COVPORCH
Permit Fee:
$0.00
_F
SuppI.Insp.Fee-.(j)Reg. OOT
_T_
070
hrs
$0.00
PME Unit Fee:
$0.00-
PME Permit Fee:
$0.00
Con's1ructio"? 7`a'�_'
T
0
Work Without Permit? 0 Yes (D No
$0.00
Advanced PI qnniD_g_f ec.-
$0.00
Select a Non -Residential
Building or Structure
T7 I
0
0
A
Trav�d f_)o(,,mneP., icaion /'r:'�.W.'
Strong Motion Fee: IBSEISAffCR
$0.60
Select an Administrative Item
1
Bldg Stds Commission Fee: IBCBSC
$1.00
SIUBTOTAILS:
$1.60.$1,502.001
TOTAIL FEE:
1 $1,503.60
Revised: 12/04/2011