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12120039 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10437 MARY AVE CONTRACTOR:ROY CHEUNG'S PERMIT NO: 12120039 CONSTRUCTION COMPANY OWNER'S NAME: SHANMUGAM PUSHPARAJ&DHIVYA 3616 CARICK PLACE WAY DATE ISSUED: 12/10/2012 OWNER'S PHONE: 4083487111 SAN JOSE,CA 95121 PHONE NO:(408)489-5988 ❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG r- ELECT PLUMB License Class 0 Lic.# C'(n 4 MECH RESIDENTIAL COMMERCIAL Contractor gAO6&21,&4 Date 12 16 �( Z I hereby affirm t y rat I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:REMODEL BATH(90 SQFT)CONVERT TO TWO BATHS (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: 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. Sq.Ft Floor Area: Valuation:$7500 1 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. APN Number:32652061.00 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 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 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 Issued by: \ Date: 9.18. Signature ti Date 40'— 2-,0(2, RE-ROOFS: ❑ OWNER-BUILDER DECLARATION All roofs 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 I hereby affirm that I am exempt from the Contractor's License Law for one of inspection. the following two reasons: 1,as owner of the property,or my employees with wages as their sole compensation, Signature of Applicant: Date: will do the work,and the structure is not intended or offered for sale(Sec.7044, 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 HAZARDOUS MATERIALS DISCLOSURE declarations: I have read the hazardous materials requirements under Chapter 6.95 of the I have and will maintain a Certificate of Consent to self-insure for Worker's California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain Compensation,as provided for by Section 3700 of the Labor Code,for the compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health& performance of the work for which this permit is issued. Safety Code,Section 25532(x)should I store or handle hazardous material. I have and will maintain Worker's Compensation Insurance,as provided for by 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 Health&Safety Code,Sections 25505,25533,and 25534. 1 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 Owner or rthor' I agent: Compensation laws of California. If,after making this certificate of exemption,I Date: — 10_ ?-(f / 2- become 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. CONRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of work's APPLICANT CERTIFICATION for which this permit is issued(Sec.3097,Civ C.) I certify that I have read this application and state that the above information is Lender's Name 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 Lender's Address 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 ARCHITECT'S DECLARATION granting of this permit.Additionally,the applicant understands and will comply I understand my plans shall be used as public records. with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. Licensed Professional Signature Date 12 1 -2 - CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION 10300 TORRE AVENUE• CUPERTINO, CA 95014-3255 CUPERTINO (408)777-3228• FAX(408)777-3333• building0-cupertino.org ❑NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION/TI ❑ REVISION/DEFERRED ORIGINAL PERMIT# PROJECT ADDRESS � aPN#//�3 �1 » AM, Cu / DO �j lJ lL,l OWNERNAME-->H£VYA HONE eloff _ `1 E-MAIL /Jx\ STREET ADDRESS CITY, STATE,ZIP / FAX CONTACT NAME PHONE E-MAIL STREET ADDRESS CITY,STATE, ZIP FAX ❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME O r,, LICENSE ER LICENSE TYPE -/0BUS.LIC# COMPANY NAME E-MAIL FAX W7 N sr 7 Q STRE T DRESS CITY,STATE ZIP PHONE S SoS� 7 2_ ARCHITECT/ENGINEER NAME LICENSE NUMBR BUS.LIC# Ae COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE DESCRIPTION OF WORK D N V ONL FAIVRoial To iNv 7411-4- EXISTING 411-4EXISTING USE PROPOSED USE CONSTR.TYPE #STORIES USE TYPE OCC. SQ.FT. VALUATION(S) EXISTG NEW FLOOR DEMO TOTAL AREA AREA AREA NET AREA BATHROOM KITCHEN OTHER REMODEL AREA REMODEL AREA REMODEL AREA PORCH AREA DECK AREA TOTAL DECK/PORCH AREA GARAGE AREA: U DETACH []ATTACH #DWELLING UNITS: IS A SECOND UNIT ❑YES SECOND STORY ❑YES BEING ADDED? []NO ADDITION? [-]NO PRE-APPLICATION ❑YES IF YES,PROVIDE COPY OF IS THE BLDG AN ❑YES RECEIVED BY. TOTAL VALUATION: PLANNING APPL# []NO PLANNING APPROVAL LETTER EICHLER HOME? ❑NO 7,5_ 5 1) . 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 have provide Ns 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 relating to buil c ns ct' n. I authorize representatives of Cupertino to enter the above-identified property for inspection purposes. Signature of Applicant/Agent: Date: SUPPLEMENTAL NFOOMATION REVJIRED PLAN CHECK TYPE ROUTING SLIP _New SFD or Multifamily dwellings: Apply for demolition permit for OVER-THE-COUNTER > ❑ BUILDING PLAN REVIEW existing building(s). Demolition permit is required prior to issuance of building permit for new building. ❑ EXPRESS ❑ PLANNING PLAN REVIEW _Commercial Bldgs: Provide a completed Hazardous Materials Disclosure 11 STANDARD C1 PUBLIC WORKS form if any Hazardous Materials are being used as part of this project. ❑ LARGE ❑ FIRE DEPT _Copy of Planning Approval Letter or Meeting with Planning prior to submittal of Building Permit application. MAJOR ❑ SANITARY SEWER DISTRICT ❑ ENVIRONMENTAL HEALTH ' BldgApp_201 1.doc revised 06/21/11 CITY OF CUPERTINO FEE ESTIMATOR— BUILDING DIVISION ADDRESS: 10437 Mary Ave. DATE: 12/10/2012 REVIEWED BY: jsg APN: BP#. *VALUATION: $7,500 *PERMIT TYPE: Minor Building Permit PLAN CHECK TYPE: Remodel, Bath (300 s.f. max) PRIMARY Residential PENTAMATION 1 R3SFDREM USE: I I PERMIT TYPE: WORK Remodel bath convert to two baths SCOPE FEE ID FLR AREA s.f. 1REMRESBAT 90 I I rtt_ I'luri C h,:c:k Y'W' 1'1E'W 01 Lw�ar. 1'trrrt"!f-c : I r ,>rrf. 1'. ,tr 1lilt:c. Pr:,7rri;Ie EhheF ;11cc°h. h-I'V1>- Otii��r°�" ,:`,Trs�> Ottr� l?ec_Insp. Li J]"ch,ln�p. kcc. h"/). Fc' 1lec. lisp. 1"'(': NOTE:This estimate does not include fees due to other Departments(i.e.Planning,Public Works,Fire,Sanitary Sewer District,School District,etc). Thesefees are based on the prelimina information available and are only an estimate Contact the De t or addn I info. FEE ITEMS (Fee Resolution I1-053 Ef: 7f 11112) FEE QTY/FEE MISC ITEMS Plein (.'heck F cep: :S'ttppl. PC Fee P/tttrth.:'l:lec�h.:F_lct: Permit Fee: $600.00 Supp/. Insp Fee Phnnh.,Mech-,' lcc f'lulnh "alerlt.il'lec° f'c rillit Fee: Cott.sttztction Tax: Adtninistrati�v FCC: Work Without Permit? 0 Yes No $0.00 ,Idlwjlcvd Phu'tlring F"i:e:S: Trove/0ocroncrttc line F'CCS" Strong Motion Fee: IBSEISMICR $0.75 Select an Administrative Item Bldy,Stds Commission Fee: IBCBSC $1.00 SUBTOTALS: $601.75 $0.00 TOTAL FEE: $601.75 Revised: 10/01/2012 er � v � ►r y, r%r- �0 Za1 r iCE Crv'rD EmSTINCT 14 MHO WALL. Ut Q "�' y t Temp. W6 CF: VAW QTY To REMMN '`'��.4 1 i—j ��"�•� i`�`t'..i'+�_,d ice. :.{��'i"'��!M��A�J�f uwr of wo a ROOM CLO CLI r ,r 2012k 10, Nr. , j : DEC 10 L7 z •.?�r i 'fir"!r,��.'f':d_.. RAL why C 43 Int A DY 4 c upsRTt tva . i✓A qw�6