08110012 CITY OF CUPERTINO y
BUILDLNG DIVISION PERMITCON TRACTCYVNF�ORMATI 1=^t• :
BUILDING ADDRESS: PERMIT NO.
OWNER'S NAME: PERMIT ISSUE DATE
A CONTROL NO.
ARCHI ECVENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMBMECH
0 0 0 0
O O LICENSED CONTRACTOR'S DECLARATION
u I hereby affirm Jut 1 am licensed under provision of Chapter 9(Commencing lob Description
with Section 7M)efOiAmon 3 of0c Business and Profession Code.and my license is
infull force and uffem. RMV&RPLC FURNCE
>M z_ License clan Lie s
=p Dau Co-manor
7W7W ARCHITECTS DECLARATION
R U I understand my Plans she be used as public msards
6
U. Licensed Pmfcssianel
m OWNER-BUILDER m Ce ContrON
COO 1 Wrtby aRrm that 1 1. aempl from the ConuanCod License city
o for IW
COO o following moon.(SeNon T oneuou Business and improve,
de nv Cale:Any cny s county
$or which requires n permit m eansttes albs,improve,de ermit,or e a sig any muewm
-z y prior"Inc its tensed ..Ot In ftnest lW applicant rossucthe Contractor's
permit m fin se Law(Chapter
2< thaWia licensed pursuant mNe provisions of theeue Buacmr'slJceruefaw(C Code)
Sq.Ft.Floor Area Valuation
yl-S that he itmempNSecuon90DO)end the
basis for
rth alleged
exe and Professions Code)or
Jut W te exempt Nemfrom end Jo base far Jo alleged exemption.Any vlolatlun of 55000
Section 7031.5 by any applicant for a Permit subjects the applicant to a civil penalty of APN Number Occupancy Type
not mom than fin hundred dollars($SDo) 34212091 . 00
❑I,u owner of tW lnopmy,or my eoplayces with wages a their sole compevaJon,
will do arewoh and Nefvumum Is not intended or offered for fee(Sec.TON,Busi.
and Professions Cade:The,Canuanors License Law does net apply m So ownv of Required Inspections
property who buildscrimpro as Jhvnen,answer doessuch wort hiesselforthrough his
own employees,provided that such improvements art not intended moffews fva s,If. -
bowevm,Ne Wilding or hvgovmhent is Sold within one year of Completion.site—I-
Wilder SOB han me Wrdm of proving that W did Out WW or improve fer pugmse of
V1 owner of the property,w exclusively conuaning with Bceved contrwdoma W
w rove IW project(Sec TON.Business and Profession Cade:)TW Contramars Li-
ceve law does nut apply to an owner of property who Wilds or improves thereon.and.
.he comrscts for such pmjona with a canusctar(s)licensed putaant or Ne Comncme.
License Law.
❑1 oro exempt under .B&P C fm this mason
Owner _5;Z Dam
COMPENSATION DECLA AT70N
1 hereby affirm under penalty of Perjury one of do following decl oommu:
1 bass and will maintain•Cerufuate of Covent to elf-boort for WmtehCmnpon-
on.as provided for by Station 3'1(10 of the Labor Cade.for the performance of IW
work for which this permit is in ed.
❑1 have and will maintain Works's Compensation Insurance,as no iced by Section
My Worrion sCor Code.for Ne perfamwmceaf theworkfor wbr Nis permituiawW '
My Workers Compev»tioo lvuramce esnia and Polity number am: '
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
rDtissmian Sued not W completed ifft permlm Is faro a hundred dollars(g100)
Or leu)
I certify that in to perfarmu ce of the amay Tor, ich this permh is issued.I shall nml
employ any person in my manors 4Ta Ne WarWn'CamperuaWn
Laws or califomi6 Dal
App I ant
NODCE TO APP ng ts e hfrcateof Flab rlio d yav uhmo t
bcehwi s t Wath res Camsor thinprovit AU of Ne mWr Code you most
�O forthwith comply with ach Provisions or mu permit shall W domed newkud.
Z ^' CONSTRUCTION LENDING AGENCY
t-.�.• 1 Mouthy affnm)had dome u acowructinn lending agency far ft performance of
C the work for which Nis Permit is uvea(Sec.3097,Civ.C.)
frJ Q lenders Name
=z 1<nders Addreu
U O 1 anify that I ban news this application and State Nu the earn,information is
IL coven.I agree m comply with all city and county aNinanas and SUM laws[Slating m
.p Wilding covtrome. .and hereby.moda mpmicntativest ofthia city to enmrvpnn Nu
r[3l aWve-mentioned property fur iapecoon purposes
(We)agree to save,indemnify and tecP harmless IW City of Cupertino against
(~y liebilion.judgments,casts ards esiginams which may in any way accrue againot said City
G,)'ja inconsequence o[Ne upeon / ^ ,/-
APPLICA ANDS AND WILL COMPLY WITH Al.l. ON-P INT Issued by: Date
SOURCE R
t f Re-roofs
SiLisowneroMplicsotnZoniusOar
HAZARDOUs MATERIALS DISCLOSURE a Type of Roof
WIII the apPliam orfuture Wilding occupantsmre orha ele baradoa mare
as defined by the Cupertino Municipal Code.Chapter 9.12.and the Health and Safety
Code.Section 25532(a)T tj++� All roofs shall be inspected prior to any roofing material being installed.
❑Yes
WIII f applicant or future Wilding aceupant usc cquipmem o devices which If a roof is installed without first obtaining an inspection,I agree to remove
aa
sit hmna a air canuminmu defined by IW Bay Area Air Quality Management all new materials for inspection.
nuiaT
1 ban mat the baccedcus materials nequiremenu under Chapter 6.95 of the Califor-
nia Health&Safety Cade,Smuau 23505.25533 and 25531.1 understand did If the Wilding
Joss sot currently tit u my responsibility W nouly Jc aceupant f Ne
Mgoimmcnu rjusificau,ofOccup Signature of Applicant Date
it
Owner or authodxad agent D All roof coverings to be Class'%a"or better
CITY OF CUPERTINO
6 , ITEMS OF 6 PERMIT RECEIPT OPERATOR: pHtg
COPY # 1
Sec : Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 34212091 . 00
DATE ISSUED. . . . . . . : 11/04/2008
RECEIPT # . . . . . . . . . : BS000006537
REFERENCE ID # . . . : 08110012
SITE ADDRESS . . . . . : 22621 POPPY DR
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : RAJ & SUJATHA KRISHNAN
ADDRESS . . . . . . . . . . : 22621 POPPY DR
CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-0802
RECEIVED FROM . . . . : RAJ KRISHNAN
CONTRACTOR . . . . . . . : TBD - TO BE DETERMINED LIC # 00096
COMPANY . . . . . . . . . . : TBD - TO BE DETERMINED
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . .
TELEPHONE . . . . . . . . :
• FEE ID UNIT QUANTITY - AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
IBSEISMICR VALUATION 5, 000 . 00 0 . 50 0 . 00 0 . 50 0 . 00
1EPERMITFE FLAT RATE 1 . 00 40.79 0 . 00 40 .79 0 . 00
1MPERMITFE FLAT RATE 1 . 00 40 .79 0 . 00 40 .79 0 . 00
1MRRAA UNITS 2 . 00 122 . 38 0 . 00 122 . 38 0 . 00
1PPERMITFE FLAT RATE 1 . 00 40 . 79 0 . 00 40 .79 0 . 00
1TRAVDOC FLAT RATE 1 . 00 40 . 79 0 . 00 40 .79 0 . 00
TOTAL PERMIT 286 . 04 0 . 00 286 . 04 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CREDIT CARD 286 . 04 MC
---------------
TOTAL RECEIPT 286 . 04
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
505 FINAL ELECTRICAL 507 FINAL PLUMBING
508 FINAL MECHANICAL
vii / vola
ST( -
CITY OF CUPERTINO
FURNACE/AC
. CUPEI"TIN0 PERMIT APPLICATION FORM
APNVc,z / 0 l 1. U U Date:
Building Address: p
Owner's Name: n Phone#: U
_I
Contractor: A Phone#: . /,fig _ f��Z� 3
Fax#:
Contractor License#: Cupertino Business License#:
Contact: Phone#: _),O _1.72 —3-TS. •
C: ���Y
Fax#:
Building Permit Info:
Elect❑ Plumb ❑ Mech ❑
Residential [SJ' Commercial ❑
Job Description: 0.MA- u
Char � Y��p1�@in ��n0-0QA
CCawen- ocjmted �+om 3fQr� 4
For Residential Installations:
Attic Rr Is' floor 2"d floor
Adhere to minimum setback requirement ❑
For Commercial Installations:
Replacement same weight ❑ Additional weight(structural calcs) ❑
Structural Calculations required for new installation ❑
New installation Planning Approval Required ❑
Cost of Project: Type of Cons�,uction (Usage Class):
l� S � I,
Strapped ❑ On Platform ❑ Bonded 0 New Location ❑ Replacement
Project Size: Express Standard ❑ Large ❑ Major❑
Valuation:
Green Building:;Please complete relevant portion of the Green Building Checklist& attach it to the
application or if applicable,include in plan set& the sheet index.
Revised 6/16/08
e