09010133 CITY OF CUPERTINO
BUILDING DIVISION PERMIT + fi7` TRACQ�t � � *
BUILDING ADDRESS: PERMIT NO.
820 KIM ST AR ONA T WINDOW
OWNER'S NAME: PERMIT ISSUE DATE
0 :,L9NG9PE; USHA 1994: 9 BASC-9M AVE STE 8_00 '�q '2809
IWARY14b. CONTROL NO.
(408) 378-4018
ARCHITEC IENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
a o p LICENSED CONTRACTOR'S DECLARATION
V I hereby affirm that I am licensed under provisions of Chapter 9(commencing Job Description
with Section 7000)of Division 3 of the Business and Professions Code,and my license is
y in full force and effect WINDWS & PATIO DOOR RPLCMNT &UPGRD ELECTRCL PANL
Z License Class Lic•>t
Date Contractor TO 2 0 DAMP
1 t:LQ ARCHITECTS DECLARATION
4�< I understand my plans shall he used as public records
AyU
g a H Licensed Professional
n OWNER-BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License Law for the
C p O following reason.(Section 7031.5,Business and Professions Code:Any city or county
K which requires a permit to construct alter,improve,demolish,or repair any structure
Zy prior to its issuance,also requires the applicant for such permit to file a signed statement
_ that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area Valuation
t- (commencing with Section 7000)of Division 3 of the Business and Professions Code)or 115 0
y that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
not more than five hundred dollars(ssoo). 35919042 . 00
❑1,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.Business Required Inspections
and Professions Code:The Contractor's License Law docs not apply to an owner of q P
property who builds or improves thereon,and who does such work himself or through his
own employees,provided that such improvements are not intended or offered for sale.If,
however,the building or improvement is sold within one year of completion,the owner-
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑I,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044.Business and Professions Code:)The Contractor's Li-
cense Law does not apply to an owner of property who builds or improves thereon,and
who contracts for such projects with a contractor(s)licensed pursuant to the Contractor's
License Law.
❑I am exempt under Sea B&P C for Pis reaso
�Iy-
owner LA 44 Date
7! WORKER'S COMPENSAP19N DECLARATION
I hereby affirm under penalty of pe/rjury one of the following declarations:
I have and will maintain a Certificate OYConsent to self-insure for Worker's Compen-
.don,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 required by Section
3700 of the Labor Code,for the performance of the work for which this permit is issued.
My Worker's Compensation Insurance carrier and Policy number are:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for ono hundred dollars($100)
or less.)
I certify that in the performance f the work for which this permit is issued,I shall not
employ any person in any m so to became sweet to the Workers'Compe tion
Laws o[California.Date vav F.
Applicant
NOTICE TO APPLICANT:If,after making this Certificate Exemption,fou shou d
become subject to the worker's Compensation previsionor the Labor Code,you must
`j.-, forthwith comply with such provisions or this permit shal(bc deemed revoked.
Z O CONSTRUCTION LENDING AGENCY
Fr tom. I hereby affirm that there is a construction lending agency for the performance of
> the work for which this permit is issued(Sec.3097,Civ.C.)
WGL A Lender's Name
]Z Lender's Address
V 0 1 certify that 1 have read this application and state that the above information is
I>~ correct I agree to comply with all city and county ordinances and state laws relating to
O U building construction,and hereby authorize representatives of this city to enter upon the
W above-mentioned property for inspection purposes.
a (We)agree to save,indemnify and keep harmless the City of Cupertino against
to liabilities,judgments,toss and expenses which may in any way accrue against said City /1
V Z in consequence of the granting of this permit. Date
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-PO NT Issued by: ✓
SOU ULATIONS.
,UC v'l tom,: C G Re-roofs
Signature of Applicant/Contractor Date
HAZARDOUS MATOIALS DISCLOSURE Type of Roof
Will the applicant or future buiWg occupant store or handle hazardous material
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
❑Yeses
If a roof is installed without first obtaining an inspection,I agree to remove
Will the applicant or future building occupant use equipment or devices which
t hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
trice?
❑Yes ONO
I have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the building
docs not currently have a tenant that it is my responsibility to notify the occupant of the
re i cns,which must be mel prior to issuance of a Certificate of a ancy Signature of Applicant Date
h ` 1 �)te All roof coverings to be Class" ''or better
Owner orauthorized agent
CITY OF CUPERTINO
6 ITEMS OF 6 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot :
APN 35919042 . 00
DATE ISSUED. . . . . . . : 01/30/2009
RECEIPT #. . . . . . . . . BS000007079
REFERENCE ID # . . . : 09010133
SITE ADDRESS . . . : 820 KIM ST
SUBDIVISION
CITY CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : KOLLENGODE & USHA NARAYANAN
ADDRESS . . . . . . . . . . : 820 KIM
CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-4323
RECEIVED FROM . . . . : USHA M NARAYANAN
CONTRACTOR . . . . . . . : CHRIS ETTEMA LIC # 22820
COMPANY . . . . . . . . . . : ARGONAUT WINDOW & DOOR, INC
ADDRESS . . . . . . . . . . : 1901 S BASCOM AVE STE 800
CITY/STATE/ZIP . . . : CAMPBELL, CA 95008
TELEPHONE . . . . . . . . : (408) 378-4018
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------
1BCBSC VALUATION 1, 150 . 00 1 . 00 0 . 00 1 . 00 0 .00
1BSEISMICR VALUATION 1, 150 .00 0 . 50 0 . 00 0 .50 0 . 00
1EPERMITFE FLAT RATE 1 . 00 40 . 79 0 . 00 40 .79 0 . 00
1ERT<200 UNITS 1 . 00 40 .79 0 . 00 40 . 79 0 . 00
1TRAVDOC FLAT RATE 1 . 00 40 .79 0 . 00 40 .79 0 . 00
1WINREP EACH 8 2 . 00 734 . 00 0 . 00 734 . 00 0 . 00
---------- ---------- ---------- ----------
TOTAL PERMIT 857 . 87 0 . 00 857 . 87 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CREDIT CARD 857 . 87 MC
---------------
TOTAL RECEIPT 857 . 87
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OWNER-BUILDER VERIFICATION
��j l �)
1. (Check one) I or my immediate family (parent,spouse or child) will perform
CA
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
s
CV
E �45 —�' - v � 1i n to tnc'
-� 0_ e C I
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.
PersorVFirm Address/City Phone Number Type of work to be
performed
.................................................................................................
I declare under penalty of perjury that the above is true and correct. I have read and understand the
Owner-Builder Information (reverse side). r
a
Property Owners Signature: :L0 .t C, In/ Date:
job Address: SS L' �re� _ C'S'/ Permit#
Any changes to the information provided on this form shall be submitted to the City of Cupertino Build
Department.
Community Development
10300 Torre Avenue
wi Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
-7UPEIQTIN0
Building Department
JOB ADD ESS: ; PERMIT# U I
O R'S NAME: G/ /IJ f)Vi PHONE # L),� c- y3 1 ec)S
GENERAL CONTRACTOR: L c>> FAX #
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following information:
SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets &Millwork
Cement Finishing
Electrical %
Excavation
Fencing
Flooring: Carpeting
Linoleum/ Wood
Glass / Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/Contractor Signature Date
CITY OF CUPERTINO
CITYCUPEf�TINO GENERAL BUILDING
PERMIT APPLICATION FORM
APN# Date: :TA/U 243 , 2W C'
Building Address: 9 2 0S' 0 e=-C--r
cU0 &j c) , c-A 64C-() 14
Mailing Address (if different from building address):
Owner's Name: K(�j.�,�A�k4Aj Phone#: 408- -7716 - 4443,6 (
U S N A v , �l 7 3 '236 � l-f
Contractor* f ° Phone: (/.408 )— deb _ 0&-'2-0
Fax: (40 16)
Contractor License#: 8
Cupertino Business License#:
Contact: "'r I t y- \d k Ra, - Phone: 4 ;S) 3 - U 4
Fax:
Residential Commercial
V� �uDO VV s p��0 �O� "L-ev-e tit t=. �T
Job Description:
Building Permit Info:
Bldg CIS- Elect Cir Plumb ❑ Mech ❑
Type of Construction (Usage Class): Occupancy Type:
1-A, 1-B ❑ II/III/V-A ❑ II/III B, IV-HT,V-B ❑- 9--D
Valuation- Square Footage:
C
Sc-
Project
Project Size: Express ❑ Standard ❑ Large ❑ Major ❑
Green Building: Please complete relevant portion of the Green Building/LEED Checklist& attach it
to the application or if applicable, include in plan set & the sheet index.
Points Achieved:
For help, contact Build it Green at www.buildit reen.or
Revised 01/07/09
y CITY OF CUPERTINO
Cin Of GENERAL BUILDING APPLICATION
CUPEI�TINO FEE SCHEDULE
Quantity/Sf Fee ID Fee Description Fee Permit Type
Group 1GENRES or
1GENCOM
1STUCOAP Stucco Applications (up to 400 sf) B
additional stucco application
1 WINREP Replacement windows/sliding glass B
door (ea 8 windows)
1 WIN�IEWSTR New Window-structural shear B
wall/masonry (includes plan ck fee)
1 EPERMITFEE Electrical Permit Fee E
1 MPERMITFEE Mechanical Permit Fee M
1 PPERMITFEE Plumbing Permit Fee P
1 ELCPLNCK Stand Alone Electric Pln Ck (hourly) E
1 MECPLNCK Stand Alone Mechanical Pln Ck(hrly) M
1PLMBLNCK Stand Alone Plumbing Pln Ck (hrly) P
1 STPLNCK-(3 Hr Min Standard Plan Check (when no E/M/P) B
when not over counter) hourly-stand alone
1BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT
TYPES
1BSEISMICR Seismic Residential B
1BSEISMICO Seismic Commercial B
1 TRAVDOC Travel & Documentation B
/ 1BUSLIC Business License B
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