08110036 CITY OF CUPERTINO -�� °.� "-� .5 *'% � ""
BUILDINCDIVISION PERAUT kCftV A�CFaQR � -4T.10N', .
BUILDING ADDRESS: PERMIT NO.
t
10140 LOCKWO D DR SANDIUM
OWNER'S NAME: PERMITLSUEDATE
NE:
t#70 CONTROL NO.
(408) 894-9072
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
w BLDG ELECT PLUMB MECN
0 0 0 0
o o LICENSED CONTRACTOR'S DECLARATION Job DBSCrI icon
U ecI nmcby arrism Net 1 am licensed under provisions of Chapter 9(commancing P
CC with Stion 7M).(Division Sof that Business and Profca ioiu Code.and my licensee
fJ
j infull m,«and effect. REPLC EXT FURNACE& INSTL NEW A/C
y l2 Z License Class Lm.g
c p Dem Conwcbr
7W ARCHITECT'S DECLARATION
I undostand my plans shall W used as public records
U
s
s In Licensed Pmfessionel
sa3 OWNER.BUILDER DECLARATION
F 1 hereby.Rim Nat I am exempt from ala Conwcmrs Lleenm Law for the
COO following..on.(Section 703 1.5,Business and Professions Cade:Any city or county
I3 V which moraines a permit to amtmcs alar,improve.demolish,or repair any structure
ZY oar to is issuance.afso nequimt de,'PlleNt for such Permit to IIIc a signed staammn
< that Im is licensed foremastintim provisions of the COmmew'f Licise law(Chapter9 Sq.Ft.Floor Area Valuation
Xg9 (commencing with Sation 1000)of Division Sof the Business and Prafusions Code)or 10500
s
52 that he u exempt Nemfrom and the basis for the alleged exemption My violation or
Section 1031.5 by any applicants fm a permit subjects the applicant to'Civil penalty of APN Number Occupancy Type
nut mart Nan five hundred dollars(M). 34214112 . 00
Lasow ork.=dpmperty.amm[i.l ycu w.ffag fu.k(Sole 044.8 mus
and dmmework,and the he ContBures Laeesse Law dofs uapply.1014,BuiaaOf Required Inspections
arepand ctry who
Code The Conuacmes nd was;law dna Out apply m a owner of 9 P
own cro who Wilds mlmpfmruch im n and who meant in work ourefl med f rwgh his
awn employees,providedorImprovements Wuuch improvements ice not iea ofc mm0ered Ire ala If,
however.Ne building oeaofb sore within ma Wert of impletion.pur pose- .
builder will have me burdi of proving that K tlitl Out build or improve for purpose of
sola.).
1!�1,as owno of the PropenY•am uelawe'll,cooracting with licensed conwnon to
c amme,t the project(Sea 1044,Business and Profosmu Code:)The Coosxmrs Li-
caese Law docs not appy m so owner of PmPmY who builds or irnProtes Nemo-,and,
who anises for such projects with a inaactorD)licensed p umm,at the Consommes
License law.
❑I am exempt under See BAPCf this
owns
WORKERS COMPENS WDECLARAnON
I hereby•Bann under
penalty of p/e/mJrmy arc mf the,following decluuiom:
Mand will maintain a Certifiam of Consent m self-iuum fm Workce$Cmnpcn-
on,as provided fee by Section 3100 of the Labor Code.for the pcomme.of me
work for which this permit is issued.
❑1 have and will maintain Workeh Compensation Insurance,as required by Section
3100 of the labor Code.for the performance of the work for which this permit is booed.
My Workers Compensation Inese.carrier and Policy number arc: -
carrier. Policy Ne.:
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
(TTusemla need,mtM complead if the pmmit is for..hundred dollen($IOIB
or mss)
1 testify dot in the performance of the work fm which Nis Iamr^it u issued,l shall nm
employ any person in uY mamerioasmhecomm subjectmthe Warkus'Compmtsation '
Lamar C"'10
AFFias.
NOTICE TO
APPLICANT.If,after making this Cartificam of Exemption,you should
become eubjcm m the Wokces Compensation provisions of Ne Labor Code,you most
0 foMwim comply with men provisions or this permit shall be dammed mvelmd.
Z rA CONSTRUCTION LENDING AGENCY
[—i ^ I hereby a Ram shad den is a iuwcuon lending agency for de performance of
a > 1M were for which this;permit is issued(Sec.3091,Civ.C)
fA lender's Name
.a7. z La-den's Md.
U 0 1 carify,that 1 have mead this application and sum that the above infmmatim is
Ty!' cmrecL T agree to comply with all city and county ordinances and sum laws relating m
Wilding construction,and herby mtharim representatives or this city m momupna the
a1mve-mentiond property for inspection purposes
(•+ CL (We)agree to save,indemnify and keep harmless the City of Cupertino again
Ln liabilities.Judgments.costs andexprssu which may in any my acme against ad City
V z in eonaxpecna of the grantimit
ng of this per
^ APPLICANT UNDERSTANDS AND WIL 0 LY WITH A N -POINT Issued by: Date
P
SOURCE EGUV`Uri
' (`�� �1�0�0 g Re-roofs
Signator'of ApplicanUBemneserbue
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future Wilding mcupantsore or handle haureau mammal
as defined by the Cupenim Municipal Coda.Chapter 9.12.and tie Health and Safety
Corm,section 25532(.)1 `A All roofs shall be inspected prior to any roofing material being installed.
CYa NO
Will me applicant or/rmum It Ming Occupant use equipment or device which If a roof is installed without firs[obtaining an inspection,I agree to remove
it hcummus air contaminants u defined by the Bay Mm
Ares Air Quality Manageent all new materials for inspection. .
uictl
Dy. No 'y
1 hers rest the hvallousmamrialarequirements under Chapter 6.95 orde Califon
ria Haim&S.fctyCade.Sections 25505.25533 am125534.1 understand thuifthe Wilding
dna at currently hots a mnan L that It u ponsibility m notify dm oec.P.nt of me
regaimmp�ts w),icn Rust ee mit tor an u of a Certificate Or a �. Signature of Applicant Date
Owrar mtothf monxac tpra I( 0 Demo All roof coverings to be Class':W'or better
CITY OF CUPERTINO
• 6 ITEMS OF 6 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec : Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . . 34214112 . 00
DATE ISSUED. . . . . . . : 11/10/2008
RECEIPT #. . . . . . . . . : BS000006580
.REFERENCE ID # . . . : 08110036
SITE ADDRESS . . . . . : 10140 LOCKWOOD DR
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . .. MADHUKAR GOVINDARAJU
ADDRESS . . . . . . . . . . : 10140 LOCKWOOD DR
CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-2614
RECEIVED FROM . . . . : MADHUKAR C GOVINDAR
CONTRACTOR . . . . . . . : MICHAEL LEE LIC # 28867
COMPANY . . . . . . . . . . : SANDIUM
ADDRESS . . . . . . . . . . : 4223 VERDIGRIS CIR
CITY/STATE/ZIP . . . : SAN JOSE, CA 95134
TELEPHONE . . . . . . . . : (408) 894-9072
• FEE ID UNIT QUANTITY AMOUNT PD-TO-DT - THIS REC NEW BAL
---------- ------------- ---------- ---------- ------ ---------- ----------
1BSEISMICR VALUATION 10, 500 . 00 1 . 10 0 . 00 1 . 10 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 . 64 0 . 00 286 . 64 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- - --------------------
CHECK
- -
CHECK 286 . 64 #1001
---------------
TOTAL RECEIPT 286 . 64
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------- ----------- -------- ----------------------------
505 FINAL ELECTRICAL 507 FINAL PLUMBING
508 FINAL MECHANICAL
o�!l o03 (�
arM�
CITY OF CUPERTINO
FURNACE/AC
e CUPEKTINO PERMIT APPLICATION FORM
APN # � � ( � � Date:
Building Address: 1014o LoCr—WOoD N CUPfe-/Tl�p/ C ssww .
Owner's Name: m A�,)H UKp,,e ` Phone# 4-0dy 6,91—V%
Contractor: rx��SE7=01
Phone#: ( �"9S"JhIUri �C $DO Fax $0 — 6
Contr or License l I� 57ro� *66 �'� Cupertino B sines License#:
Contact:
Sly b L S� Phone#:
"k . MICHAEL 1-F-F Fax#: bs� -6 - DSbS
Building Permit Info:
Elect®-- Plumb El— Mech 011/
Residential ex
Commercial
• Job Description: T
W1T# ANEW 0
(ZEPLFICE EXIS71n1C� GSA � N12W A�� �N�I )oNE2 .
For Residential Installations:
Attic ❑ 1" floor ❑ 2nd floor ❑
Adhere to minimum setback requirement V
For Commercial Installations:
Replacement same weight ❑ Additional weight(structural calcs) ❑
Structural Calculations required for new installation ❑
New installation Planning A proval Required ❑
Cost of Project: Type of Constructions Usage Class):
Strapped On Platform Ll Bonded El New Location Replacement
Project Size: Ex rens❑—Standard ❑ Lar e ❑ 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
•