12120067CITY OF CUPERTINO BUILDING PERMIT I
BUILDING ADDRESS: 21180 HAZELBROOK DR
OWNER'S NAME: IYYAVOO ARUL AND PRAKASHPATHY DEEPA
OWNER'S PHONE: 4082035936
❑ LICENSED CONTRACTOR'S DECLARATION
License Class ` 5& Lic. 4 '�?'0 ! - 7 � Z
Contractor E�Gr� �'"� �A Date
I hereby affirm that I am licensed under the provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business & Professions
Code and that my license is in full force and effect.
I hereby affirm under penalty of perjury one of the following two declarations:
1 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
Section 3700 of the Labor Code, for the performance of the work for which this
permit is issued.
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 uthorize representatives of this city to enter
upon the above mentioned prope or inspection purposes. (We) agree to save
indemnify and keep harmless th ity of Cu ino against liabilities, judgments,
costs, and expenses which ma accrue a i s aid City in consequence of the
granting of this permit. A ' ionally e a licant understands and will comply
with all non -poi ourc� ' gulati s per a Cupertino Municipal Code, Section
9.18.
Signature �'{' Date Z 3 i Z
❑ 1 OWNER- BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons:
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 & Professions Code)
1, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec.7044, Business & Professions Code).
I hereby affirm under penalty of perjury one of the following three
declarations:
1 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
Section 3700 of the Labor Code, for the performance of the work for which this
permit is issued.
I certify that in the performance of the work for which this permit is issued, I shall
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
become subject to the Worker's Compensation provisions of the Labor Code, I must
forthwith comply with such provisions or this permit shall be deemed revoked.
APPLICANT CERTIFICATION
1 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
upon the above mentioned property for inspection purposes. (We) agree to save
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
costs, and expenses which may accrue against said City in consequence of the
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.
Signature Date
CONTRACTOR: TATS INC DBA MR PERMIT NO: 12120067
ROOTER PLUMBING
44777 S GRIMMER BLVD STE C DATE ISSUED: 12/13/2012
FREMONT, CA 94538 PHONE NO: (408)271 -2822
BUILDING PERMIT INFO: BLDG f— ELECT F PLUMB I-
MECH I— RESIDENTIAL r COMMERCIAL
JOB DESCRIPTION: PROPERTY LINE CLEANOUT
Sq. Ft Floor Area: I Valuation: $1000
APN Number: 32655025.00 1 Occupancy Type:
PERMIT EXPIRES IF WO OT STARTED
WITHIN 180 DAYS OF SSUANCE OR
180 DAY F OM;E,AS' r, E NSPECTION.
lid bv`. ,1 °e.` Date:
yip
4'RE- ROOFS:
Alt' shall be inspected prior to any roofing material being installed. If a roof is
installed without first obtaining an inspection, I agree to remove all new materials for
inspection.
Signature of
Date:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
HAZARDOUS MATERIALS DISCLOSURE
I have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain
compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health &
Safety Code, Section 25532(x) should I store or handle hazardous material.
Additionally, sho I use equipment or devices which emit hazardous air
contaminants efined by the Bay Area Air Quality Management District I will
maintain co ance witk the Cupertino Municipal Code, Chapter 9.12 and the
Health & f Cod Seetions 25505, 25533, and 25534.
ne
Date:r 2 `-
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of work's
for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
Lender's Address
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Licensed Professional
CUPERTINO
GENERAL PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014 -3255
(408) 777 -3228 • FAX (408) 777 -3333 • buildingecuoeriino.org
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STREET ADDRESS
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USE OF ❑ SFD or DUPLEX ❑ MULTI- FAMILY
BLTIL.DING: ❑ COMMERCIAL
PROJECT IN WILDLAND ❑ YES I
URBAN INTERFACE AREA ❑ NO
PROJECT IN ❑ YES
FLOOD ZONE ❑ NO
I IS THE BLDG AN ❑ YES
EICHLER HOME. ❑ NO
DESCRIPTION OF WORK
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TOTAL VALUATION: �(`� �` J
I RECEIVED BY: i
By my signature below, I certify to each of the
application and the information I have prod
ordinmces and state laws r
Signature of Applicant/Agent:
owing: I - the owner or authorized agent to act on p� per ty owner's behalf. I have read this
s corre� a rea a Description of Work and verify it is accur�fe. I agree p comply V'rith all applicable local
I uth0 ' e representatives of Cupertino to enter the above -iit 5edp. /.,y for inspection pu;�oses.
Date: A G
SUPPL MENTAL INFORMATION REQUIRED
E USE ONLY
OVER- THE - COUNTER
E'
❑ EXPRESS
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❑ STANDARD
❑ LARGE
❑ h1AJOR
kLFP1✓fisct'pp= 2011.doc revised 06121111
IM-7, CITY OF CUPERTINO
FEE ESTIMATOR — BUILDING DIVISION
NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School
District, eta). These fees are based on the preliminary information available and are only an estimate Contact the Deptfor addn'1 info.
FEE ITEMS (Fee Resolution 11 -053 Ef : 7f %Ii12)
ADDRESS: 21180 hazelbrook dr
_7DATE:
12/13/2012
REVIEWED BY: sylvia
Plumb. Permit Fee: IPPERMIT
APN:
BP #:
*VALUATION: j$1,000
*PERMIT TYPE: Building Permit
k fra.;p, t'e'E':
[PLAN CHECK TYPE: Alteration / Repair
PRIMARY SFD or Duplex
USE:
$0.00
PENTAMATION 1 RPSS
PERMIT TYPE:
WORK
property line clean out
SCOPE
Permit Fee:
$0.00
NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School
District, eta). These fees are based on the preliminary information available and are only an estimate Contact the Deptfor addn'1 info.
FEE ITEMS (Fee Resolution 11 -053 Ef : 7f %Ii12)
Atc,h. Plum Ch, k
Plumb. Plan Check 0.0 hrs $0.00
1 , C hC("k
Plumb. Permit Fee: IPPERMIT
(;ltx. P�rrrair 1<e:
L h"I' '11crcP1. h -ls >
Other Plumb Insp. 0.0 hrs $45.00
Oih(r � it�c. My,
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NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School
District, eta). These fees are based on the preliminary information available and are only an estimate Contact the Deptfor addn'1 info.
FEE ITEMS (Fee Resolution 11 -053 Ef : 7f %Ii12)
FEE
QTY /FEE
MISC ITEMS
Plan Check Fee:
$0.00
= #
$23.00
Plumbing
1PRSEWER Sewer, Sanitary
Suppl. PC Fee: Q Reg. Q OT
0.0
hrs
$0.00
PME Plan Check:
$0.00
Permit Fee:
$0.00
Suppl. Insp. Fee -0 Reg. Q OT
0.0
hrs
$0.00
PME Unit Fee:
$0.00
PME Permit Fee:
$45.00
T
C `ol so- 1rction Tax:
Administrative Fee: 1ADMIN
$42.00
0
G
Work Without Permit? 0 Yes Q No
$0.00
Advanced Planning Fee.
$0.00
Select a Non - Residential
Building or Structure
0
0
i
Travel Documentation Fee: 1TRAVDOC
$45.00
Strong Motion Fee: IBSEISMICR
$0.50
Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC
$1.00
SUBTOTALS:
$133.50
$23.00
TOTAL FEE:
$156.50
Revised: 10/01/2012
CUPERTINO
CONTRACTOR / SUBCONTRACTOR LIST
Building Department
City Of Cupertino
10300 Torre Avenue
Cupertino, CA 95014 -3255
Telephone: 408 - 777 -3228
Fax: 408 - 777 -3333
JOB ADDRESS:
SUBCONTRACTOR
PERMIT #
OWNER'S NAME:
PHONE #
GENERAL CONTRACTOR: MV'
BUSINESS LICENSE #
ADDRESS: .5 r -t ,/
CITY /ZIPCODE:
*Our municipal code requires all businesses working ' e city to have a City of Cupertino business license.
NO BUILDING FINAL OR FINAL OCCUPA INSP TION(S) WILL BE SCHEDULED UNTIL THE
GENERAL CONTRACTOR AND ALL SUB RAC R E OBTAINED A CITY OF CUPERTINO
BUSINESS LICENSE.
I am not using any subcontractors P ' " -
Signature
Please check applicable subcontractors and complete the following information:
Date
V
SUBCONTRACTOR
BUSINESS NAME
BUSINESS LICENSE #
Cabinets & Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring / Carpeting
Linoleum / Wood
Glass / Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Painting / Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner / Contractor Signature
Date