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11030041 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10413 GLENVIEW AVE CONTRACTOR:PRASAD NALLAMOTHU PERMIT NO: 11030041 OWNER'S NAME: PRASAD NALLAMOTHU 10413 GLENVIEW AVE DATE ISSUED:03/09/2011 (>fWI�IER'S PHONE: 4086152434 CUPERTINO,CA 95129 PHONE NO: G LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG F ELECT r– PLUMB License Class Lic.# MECH r RESIDENTIAL r COMMERCIAL F Contractor Date I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:TO CLEAR CODE ENFORCEMENT CASE(]0413)-REPLACE (commencing with Section 7000)of Division 3 of the Business&Professions SHOWER STALL;NO ELECTRIC/MECHANICAL Code and that my license is in full force and effect. I hereby affirm under penalty of perjury one of the following two declarations: I have and will maintain a certificate of consent to self-insure for Worker's Compensation,as provided for by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. I have and will maintain Worker's Compensation Insurance,as provided for by Sq.Ft Floor Area: Valuation:$367 Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. APN Number:36911029.00 Occupancy Type: APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is correct.I agree to comply with all city and county ordinances and state laws relating to building construction,and hereby authorize representatives of this city to enter PERMIT EXPIRES IF WORK IS NOT STARTED upon the above mentioned property for inspection purposes. (We)agree to save indemnify and keep harmless the City of Cupertino against liabilities,judgments, WITHIN 180 DAYS OF PERMIT ISSUANCE OR costs,and expenses which may accrue against said City in consequence of the 180 DAYS FROM LAST CALLED INSPECTION. granting of this permit. Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. Issued by: , -�`� Dater,- Signature ater Signature Date ' OWNER-BUILDER DECLARATION RE-ROOFS: All roofs shall be inspected prior to any roofing material being installed.If a roof is I hereby affirm that I am exempt from the Contractor's License Law for one of installed without first obtaining an inspection,I agree to remove all new materials for the following two reasons: inspection. I,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, Signature of Applicant: Date: Business&Professions Code) I,as owner of the property,am exclusively contracting with licensed contractors to ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER construct the project(Sec.7044,Business&Professions Code). I hereby affirm under penalty of perjury one of the following three �4HAZARDOUS MATERIALS DISCLOSURE declarations: I have and will maintain a Certificate of Consent to self-insure for Worker's I have read the hazardous materials requirements under Chapter 6.95 of the Compensation,as provided for by Section 3700 of the Labor Code,for the California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain performance of the work for which this permit is issued. compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health& I have and will maintain Worker's Compensation Insurance,as provided for by Safety Code,Section 25532(a)should I store or handle hazardous material. Additionally,should I use equipment or devices which emit hazardous air Section 3700 of the Labor Code,for the performance of the work for which this contaminants as defined by the Bay Area Air Quality Management District I will permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the I certify that in the performance of the work for which this permit is issued,I shall Health&Safety Code,Sections 25505,25533,and 25534. 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 nero authorized agent: become subject to the Worker's Compensation provisions of the Labor Code,I must � .l�—Date: forthwith comply with such provisions or this permit shall be deemed revo d. CONSTRUCTION LENDING AGENCY APPLICANT CERTIFICATION I hereby affirm that there is a construction lending agency for the performance of work's I certify that I have read this application and state that the above information is for which this permit is issued(Sec.3097,Civ C.) correct.I agree to comply with all city and county ordinances and state laws relating Lender's Name to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes.(We)agree to save Lender's Address indemnify and keep harmless the City of Cupertino against liabilities,judgments, r and expenses which may accrue against said City in consequence of the ARCHITECT'S DECLARATION Ag of this permit.Additionally,the applicant understands and will comply wan all no -point source regulations per the Cupertino Municipal Code,Section I understand my plans shall be used as public records. 9.18. 3 � 1 � Licensed Professional Signature Date CITY OF CUPERTINO FEE ESTIMATOR- BUILDING DIVISION A ADDRESS: 10413 glenview ave. DATE: 03/09/2011 REVIEWED BY: bobs. APN: BP#: `VALUATION: $367 ;'PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration /Addition/ Repair PRIMARY ----[PENTAMATION 1 RPFIX USE: SFD or Duplex PERMIT TYPE: WORK To Clear Code Enforcement Case: replace shower stall no elect mech. SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Fixture or Trap 1BPFIXTURE 1 # $8 TOTALS: $8.00 Plumb.Plan Check 0.0 hrs $0.00 [Plumb.Permit Fee: 1PPERMIT EjOther Plumb Insp. 0.0 hrs $42.00. NOTE: These fees are based on the preliminary information available and are only an estimate. Contact the Dept for addn'l info, FEE ITEMS LFee Resolution 09-051 1i: . ?%1,%10) FEE QTY/FEE MISC ITEMS PME Plan Check: $0.00 F71= PME Unit Fee: $8.00 PME Permit Fee: $42.00 Work Without Permit? E) Yes 0 No $50.00 Ak Travel Documentation Fee: ITRA VDOC $42.00 Strong Motion Fee: 1BSEISMICR $0.50 i J M, Select an Actnmristr ive Item Bldg Stds Commission Fee: 1BCBSC $1.00 SUBTOTALS: $143.50 $0.00 TOTAL FEE-.T $143.50 Revised: 01/15/2011 CITY OF CUPERTINO 5 ITEMS OF 5 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN 36911029. 00 DATE ISSUED. . . . . . . : 03/09/2011 RECEIPT # . . . . . . . . . : BS000012863 REFERENCE ID # . . . : 11030041 SITE ADDRESS . . . . . : 10413 GLENVIEW AVE SUBDIVISION . . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . OWNER PRASAD NALLAMOTHU ADDRESS 10413 GLENVIEW AVE CITY/STATE/ZIP . . . : CUPERTINO, CA 95129 RECEIVED FROM . . . . : PRASAD M NALLAMOTHU CONTRACTOR LIC # *OWNER* COMPANY PRASAD NALLAMOTHU ADDRESS 10413 GLENVIEW AVE CITY/STATE/ZIP . . . : CUPERTINO, CA 95129 TELEPHONE . . . . . . . . : FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- -------- 1BCBSC VALUATION 367 . 00 1. 00 0 . 00 1 . 00 0 . 00 1BPFIXTURE NO OF FIXTURE 1 . 00 16 . 00 0 . 00 16 . 00 0. 00 1BSEISMICR VALUATION 367 . 00 0. 50 0 . 00 0 .50 0 . 00 1PPERMITFE FLAT RATE 1 . 00 84 . 00 0 . 00 84 . 00 0 . 00 1TRAVDOC FLAT RATE 1 . 00 42 . 00 0 . 00 42 . 00 0 . 00 ---------- ---------- ---------- ---------- TOTAL PERMIT 143 . 50 0 . 00 143 .50 0 . 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CHECK 143 . 50 #1573 --------------- TOTAL RECEIPT 143 .50 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 106 SEWER & WATER 202 UNDERFLOOR PLUMBING 301 ROUGH PLUMBING 302 TUB & OR SHOWER 502 FINAL PLUMBING ENERGY 506 GAS TEST 507 FINAL PLUMBING 512 FINAL HANDI-CAP //U �� GENERAL PERMIT APPLICATION MEP COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 MISC (408)777-3228•FAX(408)777-3333• building aakupertino.orq CUPERTINO FT PLUMBING MECHANICAL ]ELECTRICAL ❑MISCELLANEOUS PROJECT ADDRESS / /� / / / /� APN# OWNER NAME� P E-MAIL r STREET ADDRESS 7P-e�.3 >r CITY. STATE,ZIP FAX APPLICANT NAME n/_ (>y , /r'D PHONE E-MAIL STREET ADDRESS C}Cv CITY,STATE, ZIP FAX K ER ❑ OWNER-BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ENGINEER ❑ DEVELOPER ❑TENANT ACTOR NAME ©/ 9 J� ��� LICENSE NUMBER —[TICENSE TYPE BUS.LIC# COMPANY NAME ��Jl �/ E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC# COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE USE OF PROJECT IN WILDLAND PROJECT IN STRUCTURE: El Residential ❑ Commercial URBAN INTERFACE AREA C3 Yes E] NO FLOOD ZONE ❑ Yes El NO DESCRIPTION OF WORK ry�w TOTAL VALUATION: RECEIVED BY: By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on the property owner's behalf. I have read this application and the information I ve provided is correct. I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relatin o building co n. I authorize representatives of Cupertino to enter the above 'denti ed property for inspection purposes. Signature of Applicant/Agent: Date: 1p SUPPLEMENT L INFORMATION REQUIRED 6 USE`ONL OVER THE-COUNTER' EXPRESS•.°" W El STANDARD " ❑ LARGE a ❑, MAJOR MEPMiscApp_2011.doc revised 03/02/11 OWNER-BUILDER DISCLOSURE FORM is COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION 10300 TORRE AVENUE• CUPERTINO, CA 95014-3255 CUPERTINO (408)777-3228• FAX(408)777-3333- building(cr�cur)ertino.org Dear Property Owner(s): An application for a building permit has been submitted in your name listing yourself as the builder of the property improvements specified at: SITE ADDRESS APN BP# O R ME OWNER ADDRESS DESCRIPTION OF WORK: We are providing you with an Owner-Builder Acknowledgment and Information Verification Form to make you aware of your responsibilities and possible risk you may incur by having this permit issued in your name as the Owner-Builder. We will not issue a building permit until you have read, initialed your understanding of each provision, signed, and returned this form to us at our official address indicated. An agent of the owner cannot execute this notice unless you, the property owner, obtain the prior approval of the permitting authority. OWNER'S ACKNOWLEDGMENT AND VERIFICATION OF INFORMATION (DIRECTIONS: Please read and initial each statement below to signify you understand or verify this information.) . I understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner- B Ider" building permit that erroneously implies that the property owner is providing his or her own labor and material personally. I, as an Owner-Builder, may be held liable and subject to serious financial risk for any injuries sustained by an unlicensed person and his or her employees while working on my property. My homeowner's insurance may not provide coverage for those injuries. I am willfully acting as an Owner-Builder and am aware of the limits of my insurance coverage for injuries to workers on my property. 2. 1 understand building permits are not required to be signed by property owners unless they are responsible for th construction and are not hiring a licensed Contractor to assume this responsibility. 43. 1 understand as an "Owner-Builder" I am the responsible party of record on the permit. I understand that I may prect myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her name instead of my own. 44. 1 understand Contractors are required by law to be licensed and bonded in California and to list their license nubers on permits and contracts. 5. 1 understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the to I value of my construction is at least five hundred dollars ($500), including labor and materials, I may be 4, considered an "employer' under state and federal law. I understand if I am considered an "employer' under state and federal law, I must register with the state and Cleral government,withhold payroll taxes, provide workers' compensation disability insurance, and contribute to unemployment compensation for each "employee." I also understand my failure to abide by these laws may subject me to serious financial risk. 7. 1 understand under California Contractors' State License Law, an Owner-Builder who builds single-family res ential structures cannot legally build them with the intent to offer them for sale, unless all work is performed by licensed subcontractors and the number of structures does not exceed four within any calendar year, or all of the work �is rformed under contract with a licensed general building Contractor. 8. 1 understand as an Owner-Builder if I sell the property for which this permit is issued, I may be held liable for or personal injuries sustained by any subsequent owner(s)that result from any latent construction defects in the workmanship or materials. OwnerBuilderFo m_2010.doc revised 0411,4110 „r