12030052 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 22017 SAN FERNANDO CT CONTRACTOR:VISWANADHA PERMIT NO: 12030052
SREENIVASA AND ALIVELU
OWNER'S NAME: VISWANADHA SREENIVASA AND ALIVELU 22017 SAN FERNANDO Cf DATE ISSUED:03/12,2012
OWNER'S PHONE: 4086368219 CUPERTINO.CA 95014 PHONE NO:
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LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG r_— F- r
ELECT PLUMB
License Class Lic.p
DIECH RESIDENTIAL COMMERCIAL
Contractor Date
hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION: INSTALL i00AMPTEhIPORARY POWER POLE
(commencing with Section 7001)of Dirision 3 of time Business&Professions
Code and that my license is in full force and effeet.
I hereby affirm under penalty of perjury one of the following two declarations:
1 have and will maintain it certificate of consent to sell=insure for Worker's
Compensation,as provided for by Section 3700 of the Labor Code,for the
perfonnrice of the work for which dais permit is issued. Sq.Ft Fluor Area: Valuation:5388
1 have and will maintain Worker's Compensation Insurance,as provided for by
Section 3700 of me Labor Code,fur die performance of the work for which this
Permit is issued. APN Number:35712005.00 Occupancy Type:
APPLICANT CERTIFICATION
1 certify that I have read this application mrd state drat the above information is
correct.1 agree to comply with all city and county ordinances mid slate Paws relating PERMIT EXPIRES IF WORK IS NOT STARTED
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save WITHIN 180 DAYS OF PERMIT ISSUANCE OR
indemnify and keep harmless the City of Cupertino against liabilities,judgments, 180 DAYS FROM LAST CALLED INSPECTION.
costs,and expenses w4tich may acenm against said City in consequence of the
granting of this permit. Additionally,the applicmu understands mid will comply
with all non-point source regulations per the Cupertino Municipal Code,Sectiah Issued by: �w r/ �IY/Gly' Date: 3-/a-/FL
9.18.
Sienature Date.
RE-ROOFS:
❑ OWNER-RUILDER DECLARATION All roofs shall be inspected prior to any rooting material being installed If a roof is
installed without first obtaining an inspection,I agree to remove all new materials for
I hereby affirm that I am exempt from the Contractor's License Lawfor one of inspection.
the following two reasons:
I,as ownerofthe property,or nhyemployzes with wages as theirsole compensation, Signature of Appliclum Date:
will du the work,and the structure is not intended or offered for sale(Sce.7044,
Business K Professions Code)
P,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.7(44,Business S Professions.Code).
1 hereby affirm under penalty of perjury one of the following three HAZARDOUS h1ATERLAI S DISCLOSURE
declarations: I have read the hazardous materials requirements under Chapter 6.95 of the
1 have and will maintain a Cenificate of Consent to self-insure for Worker's California Health&Safety Code.Sections 25505.25533,and 25534. 1 will nmaintain
Compensation,as provided for by Section 3700 of the labor Code,for time compliance with the Cupertino Municipal Code.Chapter 9.12 and the Health d
perfommr oe of the work for which this permit is issued. Safety Cade.Section 25532(1)should I store or handle hazardous material.
1 have mid will maintain Worker's Compensation Insurance,as provided for by Additionally,should I use equipment or devices which emit hazardous air
Section 3700 of tete Labor Code,for(tic perfornana of the work for which this contantLitsasned by the Bay Area Air Quality Management District 1 will
permit is issued. mainlai with the Cupertino Municipal Code,Chapter 9.12 and time
en h e,Sections..5505...5533,and 25534.
I certifythat in the performanceof the work forwhichthispermit is issued,lshall
notemployanyperson inany mannerso as to become subject to true Worker's r ter t: � '
Compensation Paws of Cali Ibmia. If,after making this certificate of exemption,l Date: 2
become subject to the Worker's Compensation provisions of the Labor Code,I rust
forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING.AGENCY
I hereby arm that there is a construction lending agency for time performance of+wok's
APPLICANT CERTIFICATION for which this permit is issued(Sec.3097,Civ C.)
I certify that I have read this application imd state that the above information is Lender's Name
correct.I agree to comply with all city and county ordinances and sate laws rehiring
m buildingconstru 'on,and hereby authorize representatives of this city m enter Lender's Address
upon the above m nt oned property for inspection purposes.(Wc)agree to save
indeninih•and ke p tlarnlcss the City of Cupertino against liabilities,judgmcnts,
costs,and ex nshich arca accrue against said City in consequence of the ARCHITECT'S DECLARATION
grantin-Of t s p it.AJditionally, he applicant understands and will comply I understand my plans shall be used as public records.
W ith all mon p int urea regulation. her the Cupertino Municipal Code,Section
9.18. 1 Licensed Professional
Signature Das ` zo
CITY OF CUPERTINO
FEE ESTIMATOR- BUILDING DIVISION
ADDRESS: 22017 San Fernando Ct DATE: 03/12/2012 REVIEWED BY:
APN: ----FB-P#.. *VALUATION: $388
*PERMIT TYPE: Electrical Permit PLAN CHECK TYPE: Alteration /Addition/ Repair
PRIMARY SFD or Duplex PENTAMATION 1REAP2
USE: PERMIT TYPE: 10,
WORK Install 100 amp temporary ower pole.
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Services 1ERT<200 100 Amps $44
TOTALS: $44.00
Afe:h. Plan Clu,.k Phaub.Plan Check Elec. Plan Check 0.0 lirs $0.00
;Rech. Permit r•ee: Plunrh.Palma Pee: Elec. Permit Fee: IEPERAIIT
Unto+• woeh.hu7r. OIhG Plwnh brsp. Ej
Other Elea (lisp. 0.0 hrs $44.00
Aleph [nil) Fees Plumb.lap.P'ee: MCC.lny. Fee.•
NOTE: This evinmte does not include fees due to other Departnurnis(i.e. Planning.Public Works. Fire,Sanitary Sewer District.School
District,etc.). Thesefees are based on the 1welininan in ornmtion available and are only all eslinutle. Cotnact the Dept oraddn'I info.
FEE ITEMS (Fee Resolution 11-053 EH 7/1/11) FEE QTY/FEE MISC ITEMS
Plan Clieck Fec:
.Supp!.PCF'eY
PNIE Plan Check: $0.00
Permir Fee'
Suppl hisp Pee
PME Unit Fee: $44.00
PME Permit Fee: $44.00
Construction Tax.-
Administrative
ax:Administrative Fee: IADAt/N $41.00
Work Without Permit? O Yes Q No $0.00
Adilinced Plaunin,K Fees:
Travel Documentation Fee: ITRA PDOC $44.00
Strome Motion Fee: IRSE1SHICR $0.50 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $1.00
SUBTOTALS: 1 $174.50 $0.00 TOTAL FEE: $174.50
Revised: 1/19/2012
GENERAL PERMIT APPLICATION M E P
COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION
10300 TORRE AVENUE •CUPERTINO, CA 950143255
mi
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CUPERTINO (408)777-3228 • FAX(408)777-3333• buildinnglZEDDcuoerino.cra v\ (v'
❑PLUMBLNG ❑A(ECHANICAL 2ELECTRICAI. ❑NIISCQ.Lp,NE0U5
FROfELTADDRESS APNI
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OWNER NAME Q``IE /0132 lG �J7 ICS E-MAIL
S "l VLs CI ` Cl YI) o✓`^ G1 v�JGJ DL /
STREET ADDRESS CRY, STATE,ZIP FAX
CONTACT NAME PHONE EMAB.
STREETADDRESS .CRY,STATE, ZIP FAX
❑OWNER ❑ OWNER-BtlCDEat ❑ OWNEtAGENT ❑ OCNSitACTOR ❑CONTRAC ORACENT ❑ ARCHt TECt ❑EVGLUEEt ❑ OEVELOPER ❑ TENANT
CONTRACTOR NAME UCFNSE NUMBER LICENSE TYFE I BUS.LIC p
�/ COMEANY NAME / E-MAIL FAX
STREE7 ADDRESS CRY,STALE,ZIP PHONE
AR0RTECTFNOTNEER NAME LICENSE NUMBER Bus.LIC A
COMPANY NAME' E-MAB. FAX
STREET ADDRESS CRY,STATE ZP PRONE
USE OF IF=.DUP! C1M TI-FAMILY I PRO=1N W=1AND 11 YES I PRO!Et7N ❑YES ISTHEBLOGAN YES
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BUILDING: mxcS CLL URBAN INTERFACE AREA NO FLOOD ZONE ❑NO ECIG.LR HOME? ❑NO
DESCRIPTION OF WORK
TOTAL VALUATION: qJ -3'-3 A- 'QO RECE3VM BY: NR�
By tay signat=c below,I cer3fy w each of following: I I am the property owoer or authorized agent to act on rbe pmp¢y ewna's behal.`. I have:cad this
appticatien and the i cGaation I aver' 'ded is wttt j have=d the Desaiption of Work and verity it is==ate. I a&r c m conmly wid;all applicable local
ordinances and save Taws relating }Ifu'I g consm:cdon`[a cSorize reprueatatives of Cepertino to enter the aScve-i 3sed -pery for inspection pokpases.
Sivnanua of ApplicandAgcoc Daze: 3 Z 2,V7 Z/
SUP , I i Z LYFORV TION REQUIRED OFFICE USE ONLY
v
OVER-THE-COUNTER
❑ EXPRESS
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❑ STANDARD
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❑ MACE
❑ MAJOR
AEPMucApp_2011.dac revised 06/21111