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CI'T'Y OF CUPERTINO
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INFORMA'�I'100"X
BUILDING DIVISION PERMIT
paCONTRACTOR
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BUILDINGADDRESS:
SATYANARAYANA MEDICHERCA
PERMRNO03060176
OWNER'S NAME:
10092 STERN AVE
PERMITISSUEDATE
NE:
SANITARY NO. CONTROL N0.
ARCH TE•C-FIENGINEER:
BUILDING PERMITINFO
BLDG' ELECT' PLUMB MECH
0 0 0 0
LICENSED CONTRACTOR'S DECLARATION
lob Description
I hereby affirm that l am licensed under provisions or Colo., 9 (commencing
P
with Section 7051) cf Division 3 of the Business end Professions Code, and my license is
in fun fomeand edea.
DEMO OF POOL
License Clan LIC.S
Date Contractor
ARCHITECT'S DECLARATION
I undcraund my plans shall he used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
I hcmhy affirm that 1 am exempt from the Contractors License. Law for the
following mason, (Section 7031-.5, Business and Pmme.vinns Code: Any city or county
,
which requires a permit to ennstmct, Offer, improve, demolish, or repair any structure
nnn
prior to its inuo m, also requires the applicant mrsuch Permit to rile a signed statement
that he is licensed pursuant to the provisions of the Coommum's Liecnm Law (Charter 9
Sq. Ft. Floor Area
Valuation
(commencing with Section 7000) of Division 3 or the Business and Professions Code) or
37512043.00
Net he Is exempt Nemo-om and be basis for the alleged exemption. Any violation of
APN Number
Occupancy Type
Section 7031.5 by any applicant for a Permit Umpreu Ne applicant to a civil penalty of
not mom Nan Ove hundred dollars WWI.
❑ 1, M owner of the property, or my employees with wages as their ante compensation,
Required Inspections
will do the work, and the swcture is not intended or offcmd fouaie (Sce 7614. Rashness
and Profeniov Code: The Conchctofs Liceroe Law does not apply m an Owner of
propenywh t builds or improvss Hereon, and who does such work himself or through his
Own employees, Provided thatauch improvements are not intended or Offered for sale. If.
howewc Ne building Or improvement is sold within one year of complcuon, the owner.
builder will have me burden of proving Nat he did not Wild or improv for purpose of
sale.).
❑ 1, as Owner Of the property, am exclusively contracting with licensed convectors to
construct the project (Sec. 7004, Business and Professions Code:) The Conuactori L6
came law does not apply to an owner or property who builds Or improves thereon,and,
/ (
who contracts for such projects with a comracmr(0 Ne licensed pursuant to Contractor's
License Lew.
V
j
t]lem eaemProD Sec. . Bill msson
c�thies
1y r Dam D /3
i/ WORKER'g COMPENSATION RAT
1 hereby aim, under pemltY Of perjury oro Of the follow g daTIMBIORC
haw and will maintain a Cenificate of Consent to sel6Wum for Worker's Commit.
on, u provided for by Section 37W of the Labor Code, for Ne performance of the
work for which this permit is issued,
❑ I haw and will maintain Workers Compensation Insurance, as required by Section
37W of me Labor Cndc, for he performance of the work for which this perenit is issued.
My Worker's Compensation Insurance carrier and Policy number ate:
Camiec Policy No,:
CERTIFICATE OF E)UNUTION FROM WORKERS'
COMPENSATION INSURANCE
-
(ThLssmtonneednotMcompletedifthe comb Isfnrunchundmcidollart(SKIT')
tor max.)
1 centfy, But in the performance of Be work for which this Permit is issued. I shall not
employ any Flown in any manner an as a become subject o the Workers Compensation
Laws of California. Dam
Applicant
NOTICE TO APPLICANT: IC army making this Ccr iraur of Exemption, you should
become subject to the Worked Compensation pmvisiwns of the Labor Code, you men
forthwith comply with such provimmos or this Permit shall W deemed revoked.
cON LENDING AGENCY
CONSTRUCTION
' IWrehy BOtrm Natmere issued(See. constructionlendingagency l'nr the Performance Of
is a
' Na work fur which this periost is issued (Sec. 7097, Civ. Cd
Lender's Name
s
Lender's Address
I certify Nm I have mad this application end state that the above information is
edrecc. I agree to comply with all city and county ordinances and sate laws relating to
building ConsWnion, and hereby authorise representatives of this city to enter upon the
a hovPmCndiumd p np,rty for Inspection purposes.
(We) acne to lave, indemnify and keep harmless the City of Cupertino against
j liabilities, judgments, costs and expenses which may in any way same against said City
in consequence of the gaud ng of this permit
' APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by:9 z Date -(/
SOURC Ref{ LATION�--
,(' W
Re -roofs
Type of Roof
,gnewm of APPI' HAZARDOUS MATERIALS DISCLOSURE Dam
Will Ne applicant or future building Occupant atom or handle hamolous material
no defined by the Cupertha Municipal, Code, Chapter 9.13, and the Health and Safely
Code. Serum. Na
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
Will the applicant r ruwre building occupant use equipment Or devices which
lit hazardous air contaminants a defmcd by the Bay Arca Air Oval icy Management
all new materials for inspection.
suin7 i.
Yes Nu
I have mal the Wnldtws materials requirements under Chapter 6.95 of the Cafifor.
nice Hcalm&Safety Code, Seeuom25505.25533 and 25574, 1 undcraund Na if the Wilding
does not currently haw B gnat that iii myoo'nuilohly m no' fy die oceupant of N4
regain mawnteby�ay same d�nuanmwnCeNncaewaapyy S
�y9 d o Wim- b /[� I
Signature of Applicant Date
All roof coverings to be Class "B” or better
.1
Gob, m am� ;ed agent mm
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imp jn' 1 ��1(ioB
cuais,nad duo !n u " �' ON,
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UO15y114ti .yI 61 ;0_t,'l:a owes Uo
5UOPIRjoitl? Alla v;jdw o} lG!}r'viol
un sl al ptir -wl1 1.8 le 4o(oqiIto ,O)l 311naris nue sue'Aa }as $141
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04V#ER-BUILDER VERIFICATIO9
1. (Check one) I or,my immediate family (parent, spouse or child) will perform:
•A. � All the work authorized by this permit
B. _ A portion of the work
C. _ None of the work
•
If B or C is checked, complete 2 or 3 below.
2. A state licensed contractor will be hired to do:
A. _ All of the work
B. _ A portion of the work (complete section below)
Contractor Address/City Phone # State License # Type of work to
be performed
3. _ I will utilize unlicensed person(s) other than my immediate family to perform all or
portions of the authorized work. I understand that I may be an employer (see reverse side). A
Certificate of Insurance covering workers' compensation must be on file at the City of
Cupertino Building Department office.
I declare under penalty of perjury that the above is true and correct.
Owner -Builder Information (reverse
/s'id, en)._
Property Owner's Signature•
-1
job Address: I 1 'r7—CP tJ 4 -JE
40
DeQartment.
I have read and understand the
-Date:41 �!TrZ
Permit# O �L
1woo
CUPER INO
Ah
4WITY OF CUPERTINO
DEMO
PERMIT APPLICATION FORM
0
Qty.
Anuli blel Fee ID
Fee Dp..crrintinn
Fee r7mnn
BPERMFEE
APN # l
Date:
/
Building Address: b 9 2 S TE R A V b XA0
Owner's Name:S `i n� R IZp�(µ ri (a
MEN C44 GORCA
Phone #: gyp^S^ 5 7 S Z
BUILIDNG
Contractor:
License #:
Contact:
Phone #:
BUILIDNG
Applicant/Contractor:
Building ermit Info: "
Bldg Elec P b' Mech
Plan Check Fee
escription:
Residential: o erci
Sq.Ft. Floor Area:
$/Sq.Ft.:
Architect/Engineer:
Valuation:
r
Type of Construction:
Occup Grou
0
Qty.
Anuli blel Fee ID
Fee Dp..crrintinn
Fee r7mnn
BPERMFEE
Bldg Permit Fees
BUILIDNG
BSEISMICOM
Seismic Commercial
BUILIDNG
BSEISMICRE
Seismic Residential
BUILIDNG
BPLANCHK
Plan Check Fee
BUILIDNG
BUSLIC
Business License
BUILIDNG
0
CITY OF CUPERTINO
Item 1 of 1 PERMIT RECEIPT
Sec: Twp: Rng: Sub: Blk: Lot:
APN 37512043.00
DATE ISSUED.......: 06/26/2003
RECEIPT #.........: 22298
REFERENCE ID # ...: 03060176
SITE ADDRESS .....: 10092 STERN AVE
SUBDIVISION ......
CITY .............:
IMPACT AREA ......
OWNER ............: SATYANARAYANA MEDICHERCA
ADDRESS .......... 10092 STERN AVE
CITY/STATE/ZIP ...: ,
RECEIVED FROM ....: SATYANARAYANA
CONTRACTOR .......: LIC # *OWNER*
COMPANY ..........: SATYANARAYANA MEDICHERCA
ADDRESS ..........: 10092 STERN AVE
CITY/STATE/ZIP ...: ,
TELEPHONE ........:
FEE ID UNIT
-----------------------
BPERMFEE VALUATION
BPLANCHK PERMIT FEE
BSEISMICRE VALUATION
TOTAL PERMIT :
METHOD OF PAYMENT
-----------------
OTHER
TOTAL RECEIPT :
VOICE ID
704 DEMO
0
QUANTITY AMOUNT PD -TO -DT
5,000.00 107.00 0.00
107.00 90.95 0.00
5,000.00 0.50 0.00
---------- ----------
198.45 0.00
OPERATOR: conniew•
COPY # : 3
AMOUNT" NUMBER
------------ ------------------
198.45 VISA
198.45
DESCRIPTION VOICE ID DESCRIPTION
•
THIS REC
NEW 1310
-- --------
107.00
----------
0.00
90.95
0.00
0.50
0.00
----------
198.45
----------
0.00
AMOUNT" NUMBER
------------ ------------------
198.45 VISA
198.45
DESCRIPTION VOICE ID DESCRIPTION
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CITY OF CUPERTINO
BUILDING DIVISION PERMIT
CONTRACTOR INEORMATION:�
BUILDING ADDRESS:
SATYANARAYANA MEDICHERCA
PERMIT NO03060176
OWNER'S NAME:
10092 STERN AVE
PERM"I55UEDATE
E:
SANITARY NO. CONTR07N0.
'HITEClUENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 I� t� 0
LICENSEDCONTRd underSDECLARATION
1 hereby mal. am under of Chapter 9 (commencing
Job Des �Qn t1 W ��rail
P 421W %I
Profess
n mfk) of Division J of the Business; Rofcuinm Code. asW my license b
0),df ofBu and
wi toil
/f"�0
ftoc
L LicenseGlua
DEMO OF POOL
1 5 2003
Date Co. r
Dam GnmfSCL
JUL
ARCHITECTS DECLARATION
I understand my plana shall be used as public rccnNa
per
BUILDING
Licensed Pmmasional
OWNER BUILDER DECLARATION
1 hereby .(firm that 11. exempt from the Contractors Lew for the
Any
following trema Permian ]fl Co :
maso C
Business and Professions Cwle: Any city or county
which Permit m construct, alar, improv, demolish, or repair any structure
isms a
nnn
ccrtl
its ursth I for such Permit micessigned Faumem
prior tosl issuance,also requires the provisions
he thcprovivisio nim cmm�cmrsndProfe,w(Chapter 9
Sq. FL Floor Area
Valuat)on
(that
(commencing with Section 7000) of Division J the Business and Professions Cork) or
commesficewithSection7
she alleged
that he is exempt therefrom and the buss for the alleged exemption. Any violation of
37512043.00
APN Number
Occupancy Type
Section 7031.5 by any applicant for a permit objects the applicant to a civil penally of
not mon than five hundred dollars (SSW).
Q I, u owner of the property, or my employees with wages u their sok compensation,
- —DEMORe Required Inspections
will do che work and the someone is not intended or offered muek(Sec.]DN, Business
and Pm(euiom Code: The C.m m.e. License Law docs not apply ban owner of
q p
property who builds or improves i1mmon,and who domauch work himsel(or through his
own employees, provided that such improvements are not intended or offered rorule. If,
however, the building or improvement Is sold within one year orcomplefion, the owner•
builder will ban the burden of proving chat be, did not build or improve for purpoac or
sal..).
c I. as owner of me property, am exclusively convecting with licensed convectors to
construct the pmjm (Sec. 7044. Business and Professions Code:) TM1e Condubr's Lt.
come Law doss not reply to an owner of progeny who builds or improv thereon, and.
who Contracts for such projeN with a eonVactor(O licensed pursuant or the CMVacto(a
Lleenu Law.
Q1 impirenun Sec. ,B&PCf this rtuon.
r r"N Date ! Ui
WORKER'S COMPENSATION RIeC RAT
I hereby nffsmr under penalty of perjury one of the follow' g dccluethns:
hate and will maintain a Certificate of Consent to.1 Noun re for Worker's Cumpem
as provided for by Section 37M of the labor Code. rot me perfemen a of the
Far which this permit is issued.
❑ I haw and will maintain Worker's Compensation Insurance, u required by Sccdon
37M of the labor Code, for Be performance of the work for which this permit is issued.
My Worker, Compensation Insurance carrier and Policy number art:
Cartier. Polity No.: _
CERTIFICATE OF E%EM PION FROM WORKERS
COMPENSATION INSURANCE
(This acefirm need not becompleud Bthe permit Is forone hundred dollar (5101)
or leas.)
I comfy that in the performance of the work for which this permit is issued. I shall not
.
employ any prison in any mortician as In become subject to the Workcts' Compcnsetion
-
Laws or California. Dau
Applicant
NOTICE TO APPLICANT: IL after making this Certificate of Exemption, you should
1Ccome subject to the Worker's Compensation provisions of lM labor God, you must
forthwith comply with such provisions or this Permit shall M deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that tome its emuWcton lending agency for one perfurmmce of
the duh for which this permit is issued (Sec. ]09], Civ. C.)
Lender's Namc
4nder's Address
1 certify that 1 have read this application and sum that the above information is
conecL. 1 egme to comply with all city and county onfinances and sure laws rclering to
building Commotion. and hereby authariw representatives or Or&city to enter upon the
above. (We) are property for inspection purposes.
(We) agate to taw, indemnify and keep hay in an the City of Cupertino against
ecticutmenu casts and expenue which may in any wase acerae against said City
f
in Connecticut,
AcPLICANT of the grunting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -PO NT
Issued by: Date
SOURC RExa LATION - b
,(
Re -roofs
Type of Roof
ynuurc of Appli hVComrumr �� Dau
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building Occupant store or handle b t .mous material
u defined by the Cupertino Municipal Cudc, Chapter 9. 12, and the Health and Safety
Code, Se❑csecd 25531(.)? , , Nn
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
Win the applicant,car ramrc building npanL n equipment or devime which
mit hovmdous air contaminants is; defined by the Bay Area Air Quality Management
all new materials for inspection.
et?
❑Yes 11hTu
I have mad the hmardrmcmaurials mquiremenu under Chapter 6.95 of the Califon
ria Health & SafetyCork. Sect.25505,25533 and 25534.1 understand chuif IM building
dma not cunendy hew . moat. mat it1 y reapom,.biddy b no'fy the occupmt of me
myvircsncn whichpruybCmc dr landentecofaCcnlncauoa ;01
Signature Signature of Applicant Date
All roof coverings to be Class "B" or better
--
Owner
or aurhoriacJ agent oak