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06080081 T CITY OF CUPERTINO �CQ08� CUPEI�F PERMIT APPLICATION FORM A Ilk N# 2I' n� Date: Building Address: /0657 44r-ry tJAy Mailing Address (if different from building address): Owner's Name: Phone#: Contractor: License#: YO �. T e/0 - e254-3 4/ Contact: X tN�, 74 Phone:(1168 k X02-836� Cupertino Business License#: Fax: ( cx) 1?2 N3 Building Permit Info: u�(�rr /ark 4 2.cy Bldg ❑ Elect g— Plumb ❑ Mech ❑ Job Description: Residential IRL Commercial ❑ Sq.Ft. Floor Area: / Sq.Ft.: Cost of Project: Occupancy Group: a0C7 R-3 Type of Construction: Please check this box if the project is a `^ second-story addition: ❑ ro'ect Size: Standard ❑ Laze ❑ Major ❑ Quantity Fee ID Fee Description Fee Group BAPPLOTHER Other Appliances MECHANICAL BBOILERI Boiler<= 100,000 Btu MECHANICAL BBOILER2 Boiler> 100K to 500K Btu MECHANICAL BBOILER3 Boiler> 500K to 1M Btu MECHANICAL BBOILER4 Boiler> 1M to 1.75 M Btu MECHANICAL BBOILER5 Boiler> 1.75M Btu MECHANICAL BCONSTAX Construction Tax BUILDING BCONSTAX Ind/Off/Comm/Quasi BUILDING BCONSTAXBQ Con. Tax for BQ Zone BUILDING BCONSTAXH Hotel and Motel BUILDING BCONSTAXR Constax—Resi/Mobile BUILDING BELEC1000 Elec 600V<= IOOOA ELECTRICAL BELEC1001 Elec 600V > IOOOA ELECTRICAL BELEC200 Elec Svcs 600V<=200A ELECTRICAL BENERGY Energy BUILDING BENERGYADD Energy Add Multi BUILDING ` BINVESTIGA Investigation fee BUILDING I 1 of 3 MO CITY OF CUPERTINO CUPEI�TINO PERMIT APPLICATION FORM QuantityFee ID Fee Description Fee Group BMISCELL Miscellaneous Fee BUILDING BMITIGATC Comm. Housing Mit. Fee BUILDING BNUCOMME New Comm Electric ELECTRICAL BNUCOMMM New Comm Mechanical MECHANICAL BNUCOMMP New Comm Plumb PLUMBING BOVERTIME Inspection Overtime BUILDING BPBACKFLOW Atmospheric Vacuum PLUMBING BPCESSPOOL Cesspool PLUMBING BPERMFEE Bldg Permit Fees BUILDING BPFIXTURE Pblg Fixture PLUMBING BPGAS Gas Piping System Fee PLUMBING BPINTERCEP Ind Waste Interceptor PLUMBING BPLANCHK Plan Check Fee BUILDING BPLANCKADD Plan Check Add Multi BUILDING BPLANCKREP Plan Check Repeat Fee BUILDING BPREPIPE Re i e Of Fixtures-_; PLUMBING BPSEWAGE Sewage Disposal PLUMBING BPSEWER Sewers PLUMBING BPSPRINK Lawn S rinklerBackflo PLUMBING BPSTORM Storm/Rain Water PLUMBING BPTRAP Kitchen Trap PLUMBING BPVENT Alt of Drain &Vent PLUMBING BPWATER Install/Alter Water Pie PLUMBING BPWHEATER Water Heater/Vent PLUMBING BPWSVCS Main Water Service PLUMBING BREINSPECT Reinspection Fee BUILDING BREMACOVER A/C Unit> 10,000 cfm MECHANICAL BREMAIRHAN A/C Units <= 10,000 cfm MECHANICAL BREMAPPLI Appliance Install MECHANICAL BREMBUSWAY Remodel Busways ELECTRICAL BREMFIXT Lighting Fixtures ELECTRICAL BREMFURN Relocation of Fumace MECHANICAL BREMFURNOV Relo Furnace> I OK btu MECHANICAL BREMHEAT Heater Installation MECHANICAL BREMINHOOD Installation of Hood MECHANICAL BREMMISC Mise Apparatus ELECTRICAL BREMNRAPP Rem Non-Res Appliance ELECTRICAL BREMPOLE Pole/Platform Fixture ELECTRICAL BREMPOWER Power Device/Apparatus ELECTRICAL BREMRECEPT Rc tl, Switch & Outlets ELECTRICAL BREMRELOCA Relocation of Hood MECHANICAL BREMREPALT Repair/Alter Heating MECHANICAL BREMRESAPP Remodel Res Ap Hance ELECTRICAL 2of3 R- CITY OF CUPERTINO PERMIT MIT APPLICATION FORM uantity Fee ID Fee Description Fee Group BREMSIGNAD Rmdl Signs Add Branch ELECTRICAL BREMSIGNS Remodel Signs, Marquee ELECTRICAL BREMTHEATR Theatrical Lighting Fix ELECTRICAL BREMVENFAN Vent Fan Single Duct MECHANICAL BREMVENSYS Ventilation Systems MECHANICAL BSCBLVD Scb Specific Plan BUILDING BSEISMICOM Seismic Commercial BUILDING BSEISMICRE Seismic Fee Res BUILDING BSPECIAL Special Insection BUILDING BSWIM Swimming Pool BUILDING BTEMP Temporary Power ELECTRICAL BTEMPPERM Temporary Bldg Permit BUILDING BTEMPSVCS Ternp Dist Svcs ELECTRICAL BUSLIC Business License BUILDING ELECTRIC Electrical sq foot ELECTRICAL EPERMITFEE Elec Permit Issuance ELECTRICAL MPERMFEE Mechanicals . foot MECHANICAL MPERMITFEE Mech Permit Issuance. MECHANICAL PPERMITFEE Plumbing Permit Issue PLUMBING PPLBG Plumbing Fee sq foot PLUMBING PLLONGRNGC Plannin.g LR Comme/Multi-Fam PLANNING PLLONGRNGR Planning Long Range Residential PLANNING ZADDCHG Address Change BUILDING 3 of 3 CITY OF CUPERTINO BUILDING DIVISION PE IT RAC�.n� �MQN BUILDING ADDRESS: 12111417110.0(5080081 10657 LARRY W OWNER'S NAME: PERMRLSUEDATE rtKISHORE KASAMETTY NE: SAMTABY N0. CONTROL N0. ARCHITEC(ENGINEER: BUILDING PERMITINFO BLDG ELECT PLUMB ME[N I� l� wg LICENSED CONTRACTOR'S DECLARATION JOb DDSCTIpUOn i U L hereby strikes Nn 1 used n licenunder pmvism"of Chapter 9(Commencing with Secdon70M)or Divirion 3ofthe BaaioeaaditleSSiuns Code, myliceNcis inflit ameanderc UPGRADE 100 AMP TO 200 AMP 4 LlceNcClas, - Lk.g ig 4'23",3 Data cpmmcmr Vi2d & T,a ARCHRECI'S DECLARATION 1 undersand my plana shall he used an public records rub 7 .0 Licensed Pmfcs.won\I OWNER-BUILDER DECIwRATION mue :n C I hereby.Smi that 11. exempt .e the fond.. rs Licence Law for the 5 O� following mason.(Scotian 7onstruBusiness and improve. dem i Code:Any ciry Structure which its Water= •permit re cores arae tlkc.improm,h paratah,or repair ed torment -zi!^ priarbits isswncc.ala mquirealM applicant for wch Mrmitw filo signed statement ego that WInI C=dpuraaantmtmproliamNOfmacommencesU..I.Sw(a\par9 Sq R.FloorArea Valuation $ (commencing with Section 7000)of Division3oftheBusinesssMPmrnaioNCudc)of $2200 Nm he k exempt Iherefrum and Ila basis rte the alleged exemption.Any viokd'on of Section 7031.5 by any applicant for a permit subjects die applicant an•Civil penalty of APN Number Occupancy Type not more Than an hundred dollars($500). ❑I,uowmaafthepmpmry,amywplpywwithw V3UthC4alecornpenadon, P49A9199 HA wm do the work.and the almmumis.1 mknaedaraffrered Ansal,(Sec.TOM.Business Required Inspections Nd Prn(CaION Cade:The ConUKtars License Law does nal apply as N awMf of 9 P prop who employees.provided impNMJ Namara,and WM=nottch W tied oroelf arNmn{b his ownver,thbuilding or prcouchimprawrnanuerenotean fmproffered for We1f. however,the building or ImprowmmtIs Coldwithin as yw of mproe for purpose w10 haw the bmdcn a(pmvinp that he did nm build or Improve(or puryoxe of ❑1,as owner of de property,am exclusively Contracting with licensed Conua7on a Construct the project(Sec.7044.Businm and Profeadau Cade:)The Conlrsnnrs U- cove law dean not apply as an owner of property who builds or improves then:on,and, who ca turn ca for such projects with a eominsctor(s)!laved penitent a the Canuactors License U- ❑lam essman umbo s. .B k P C ror this masa Owner Data WORKERS COMPENSATION DECLARATION I hereby alarm under penalty of perjury as of use following declarations: 1 ham and will maintain aCWOaa of Consent in self-Insure for WortrrsCorrect. sadm,as provided for by Section 3700 of Ile Mbar Code,for the perormaCo of this wph for which this permit Is ivied. ❑1 have ad will maintain Worker's Compensation InsuranCo,a required by Section 37W 0(the labor Cade,far the performance of the work for which this permit is Issued. ' My Workers Compensation Insurance carrier and Policy number are: Carrier. Policy No.: CERTIFICATE OF EXEMPTION FROM WORKERS COMPENSATION INSURANCE (1T4 section need not be completed if the permit Is foram hundred dollars(SIM) or less.) I certify that In the performance of the work far which this permit 4 Wised.I shall at employ ay person in ay maracas obaoma subjects the Workers'Confirmation Laws of California.Date Applicant NOTICE TO APPLICANT. ,a making this Certificate of Exemption,you should become subject a Me Wore k ompctuadon provisions of the labor Code,you muss .J v�Z, forthwith comply with salp vlsioNor Nu permitshall berimmed rooked. Z O CONSTRUCTION LENDING AGENCY f+ I hereby affirm that them is a cannmctlon lending agency for lM perfoonanm of CL the work for which this permit is Luwd(Sec.3(97,CW.C.) U.� Lenders Name D.Q Landers Md. U Q 1 CoNfy Na I have read Nia application and was that the abow information 4 Uy t'^ correct,1 agree to comply with all city and county ordinances and aux laws rcladng in 0U building construction,and hereby Antitoxin mprescnutiws of Nis city to enter upon the above-mentioned property for inspection purposes. (We)agree to save,indemnify and keep harmless the City of Cuperino against L4 y liabilities.judgments,costs and eapensa which may in any way.Cote against aid City U Z in comseguence of the granting of this pass ^ APPLICANT UNDERSTANDS AND LL COMPLY WITH ALL NON-POINT Issued by: Date ( ( _0Z SOURCEREGU 7[O •ORe-roofs Signmum of eanUContramr DO: xAznaoeus MATERIALS DIscLOsuRE Type of Roof W applicant Ortoo=building ocmpat Rare or haMk hazardous material as deo by the Capenia Municipal Code.Chapter 9.I2,and the Health and Safety Cade,Section 35532(a)? 1 All roofs shall be inspected prior to any roofing material being installed. ❑Yes ®Nu Will the applicant or future building externalora equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove' coal,hxaardnns air mnumiruna a darned by the Bay Area Air Quality Management all new materials for inspection. District? pYes p 1 have mal the haadousmsterels requirements under Chapterd.95of the Califor. nla Hcakkilt Safcty Cade,$rations 755115.15533 ami 1 undersand thmif cite building I ans not currently haw a anal Net it 4 my responsibility In Scary the meopat of the requiremcroserhahm bepriarm ia eracwnatoor91-/1­ o�capwRy. Signature of Applicant Date owner or d ", O- Dao' All roof coverings to be Class"Bra or better Community Development 10300 Torre Avenue SI -4 Cupertino CA 95014 Telephone(408)777-3228 CITY OF Fax(408)777-3333 46UPEkTINO Building Department JOB ADDRESS: PERMIT # 0GS7 L c , 0 ' aD OWNER'S NAME: PHONE # V412- 2D21 GENERAL CONTRACTOR. 1; I F # I am not using any subcontractors: b'—6 6 S' ture Date Please check applicable subcontractors and/D pplete,the following information: SUBCONTRACTOR B SINESS 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 O /Contractor Signature Date CITY OF CUPERTINO �m 1 of 1 PERMIT RECEIPT OPERATOR: amyw COPY # 2 Sec : Twp: Rng: Sub: Blk: Lot: APN . . . . . . . . : 31602011 . 00 DATE ISSUED. . . . . . . : 08/11/2006 RECEIPT # . . . . . . . . . : 35602 REFERENCE ID # . . . : 06080081 SITE ADDRESS . . . . . : 10657 LARRY WY SUBDIVISION . . . . . . CITY . . . . . . . . . . . . . : CUPERTINO IMPACT AREA . . . . . . OWNER . . . . . . . . . . . . : KISHORE KASAMETTY ADDRESS . . . . . . . . . . : CITY/STATE/ZIP . . . : , RECEIVED FROM . . . . : AN KY ELECTRIC CONTRACTOR . . . . . . . : LIC # COMPANY . . . . . . . . . . : ADDRESS . . . . . . . . . . : CITY/STATE/ZIP . . . : , TELEPHONE . . . . . . . . : �EE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------- - ----- ---------- ---------- ---------- ---------- ---------- BENERGY PERMIT FEE 1 . 00 34 . 86 0 . 00 34 . 86 0 . 00 BELEC200 METERS 1 . 00 29 . 43 0 . 00 29 .43 0 . 00 BSEISMICRE VALUATION 2, 200 . 00 0 . 50 0 . 00 0 . 50 0 . 00 EPERMITFEE FLAT RATE 1 . 00 38 . 37 0 . 00 36 . 37 0 . 00 BUSLIC FLAT RATE 1 . 00 105 . 00 0 . 00 105 . 00 0 . 00 ---------- ---------- ---------- ---------- TOTAL PERMIT 208 . 16 0 . 00 208 . 16 0 . 00 METHOD OF PAYMENT AMOUNT NUMBER ----------------- ------------ ------------------ OTHER 208 . 16 VISA TOTAL RECEIPT 208 . 16 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- -------- ---------------------------- -------- ---------------------------- 304 ROUGH ELECTRICAL 501 FINAL ELECTRICAL ENERGY 505 FINAL ELECTRICAL