11090062I CITY OF CUPERTINO BUILDING PERMIT I
BUILDING ADDRESS: 11892 PLACER SPRING CT
OWNER'S NAME: RAM SUBRAMANIAM
f)1`"NER'S PHONE:
as LICENSED CONTRACTOR'S DECLARATION
License Class T� `/ Lic. # 3 D f 7 �G
Contractor ? JCO �a/'t $ 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:
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
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 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. c�
Signature _� -� ate `� /f/
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons:
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,
Business & Professions Code)
I, 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:
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
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
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
upon the above mentioned property for inspection purposes. (We) agree to save
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
•osts, and expenses which may accrue against said City in consequence of the
anting 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
CONTRACTOR: G RYCO cotqs 1 1 I PERMIT NO: 11090062
DATE ISSUED: 09/09/2011
PHONE NO:
BUILDING PERMIT INFO: BLDG F ELECT f— PLUMB r
MECH RESIDENTIAL COMMERCIAL I—
JOB DESCRIPTION: SFD, REPLACE 22 SF OF SIDING AT EXISTING SFDWL
*SEE NOTES*
Sq. Ft Floor Area: I Valuation: $675
APN Number: 36655007.00 1 Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
Issued by:/''�`"~ '�- Date: f/
RE -ROOFS:
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
inspection.
Signature of Applicant:
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(a) should I store or handle hazardous material.
Additionally, should I use equipment or devices which emit hazardous air
contaminants as defined by the Bay Area Air Quality Management District I will
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
Health & Safety Code, Sections 25505, 25533, and 25534.
Owner or authorized agent: Ir p— //-
Oen, -A,Date: l
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
3 ITEMS OF 3
CITY OF CUPERTINO
PERMIT RECEIPT
Sec: Twp: Rng: Sub: Blk: Lot:
APN ........: 36655007.00
DATE ISSUED.......: 09/09/2011
RECEIPT #......... BS000014713
REFERENCE ID # ...: 11090062
SITE ADDRESS .....
SUBDIVISION ......
CITY .............
IMPACT AREA ......
11892 PLACER SPRING CT
CUPERTINO
OPERATOR: TraciC
COPY # : 1
OWNER RAM SUBRAMANIAM
ADDRESS 11892 PLACER SPRING CT
CITY/STATE/ZIP ...: CUPERTINO, CA 95014-5102
RECEIVED FROM BRYAN J VANWAGONER
CONTRACTOR TBD - TO BE DETERMINED LIC # 00096
COMPANY TBD - TO BE DETERMINED
ADDRESS ..........
CITY/STATE/ZIP ...:
TELEPHONE ........:
FEE ID UNIT
QUANTITY
AMOUNT PD -TO -DT
--
THIS REC
NEW BAL
-----------------------
1BCBSC VALUATION
----------
675.00
----------
1.00
0.00
1.00
0.00
1BSEISMICR VALUATION
675.00
0.50
0.00
0.50
0.00
1SIDEOTHER SQ FEET
22.00
392.00
----------
0.00
392.00
----------
0.00
----------
TOTAL PERMIT
----------
393.50
0.00
393.50
0.00
METHOD OF PAYMENT
AMOUNT
REFERENCE
------------------
NUMBER
----------------- ---------------
CHECK
393.50
223
---------------
TOTAL RECEIPT
393.50
CUPERTINO
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT - BUILDING DIVISION
10300 TORRE AVENUE - CUPERTINO, CA 95014-3255
(408) 777-3228 - FAX (408) 777-3333 - building(a)-cupertino.or
❑ NEW CONSTRUCTION ❑ ADDITION Lr ALTERATION / Tl ❑ REVISION /DEFERRED
ORIGINAL PERMIT #
PROJECT ADDRESS j + �/ 2— Pincer r Ii \tom, ��
l l('VO"
APN # 34<r / n
l�(!y
OWNER NAME 1 Ci 1PHOPF� _ a �0
�A 5 d b Kq A (A vv` I l�l,�JTC�2J
E-MAIL
STREET ADDRESS ( I V a_ P /� C. r5 CITY, STATE, ZIP
f
FAX
CONTACT N
V
FaN W 4� dNe_r-
PHONE
STREET ADDRESS
CITY, STATE, ZIP
FAX
❑ OWNER ❑ OWNER -BUILDER ❑ OWNERAGENT CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME g p S
LICENSE NUMBERc t 7
LICENSE TYPE
BUS. LIC #
COMPANY NAMEAJ
(G
E-MAIL
FAX
STREET ADDRESS
33 S -C M
CITY, ST TE, ZIP
S.4*-) Sos Gq Mf
PHONE
31
ARCHITECT/ENGINEER NAME
LICENSE NUMBER
BUS. LIC #
COMPANY NAME ---...._____.._-._...
E-MAIL
FAX
STREET ADDRESS
................ .
CITY, STATE, ZIP
PHONE
DESCRIPTION OF WORK
Z 2, 1L v be r- I n1 (r' 1Q e rn4 -
EXISTING USE
PROPOSED USE CONSTR.
TYPE
# STORIES
USE
TYPE
OCC.
SQ.FT.
VALUATION (5)
EXISTG
AREA
NEW FLOOR
AREA
DEMO
AREA
TOTAL
NET AREA
a
V
—_3%�
/
BATHROOM
OTHER
REMODEL AREA
ODEL AREA
REMODEL AREA
PORCH AREA
DECK AREA
TOTAL DECK/PORCH AREA
GARAGE AREA: LJDETACH
I
❑ 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
i
By my Signature below, I certify to each of the following: I am the property owner or authorized agent to act on the prrperty owner's behalf. I have read this
application and the information I have pro ided 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 relating to I ng construction. I authorize representatives of Cupertino to enter the above -identified property for inspection puiposes.
Signature of Applicant/Agent: Date: l
SUPPLE INFORMAY16N REQUIRED
PLAN CHECK TYPE
ROUTING SLIP
_ New SFD or Multifamily dwellings: Apply for demolition permit for
`L> OVER-THE-COUNTER
U BUII DING 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
C1 STANDARD
ElPUBLIC 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
El MAJOR
El SANITARY SEWER DISTRICT
submittal of Building Permit application.
❑ ENVIRONMENTAL HEALTH
BldgApp_201 Ldoc revised 06/21/11
w 6.AOCLP?�'
CITY OF CUPERTINO
FEE ESTIMATOR - BUILDING DIVISION
ADDRESS: 11892 placer spring ct. DATE: 09/09/2011 REVIEWED BY: bobs.
APN: BP#: 'VALUATION: $675
"PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration / Repair
PRIMARY PENTAMATION 1 GENRES
USE: SFD or Duplex PERMIT TYPE:
WORK replace 22 sq. ft. siding at existing sfd.
SCOPE
----------- --------- 7; E�
ED
rti.._t_ o,.,,.a- Qa, nkirirf .Qrhnn/ DiStrirt. QtGI.
NOTE: This estimate does not tnctuae fees uue to utnr. L -Fla v.- � ��«� •• � -- - - -
_-' ft.a [)ant far addn'/ info.
Theseees are base# on tnepreaminary in ornueuu.i
FFEEITEMS (Fee Res•ohttion 11-053 Et1: %1;'111
Fee:
uvuisuum �•�
FEE
�• �•••
QTY/FEE
-
MISC ITEMS
$0.00
22 s.f.
$392.00
Siding
ISIDEOTHER All Other
Supp.ee: Reg. () OTF0.07hrs
$0.00
PME Plan Check:
$0.00
Permit Fee:
$0.00
Suppl. Insp. Feer Reg. C) OT
kl0
hrs
$0.00
PME Unit Fee:
$0.00
PME Permit Fee:
$0.00
0
Work Without Permit? Q Yes (F)
.Advanced Planning Fire:
No
$0.00
$0.00
Select a Non -Residential
Building or Structure
E)
0
Strong Motion Fee: 1BSEISMICR
$0.50
Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC
$1.00
SUBTOTALS:
$1.50
1 $392.00 TOTAL FEE:
$393.50
Building Department
City Of Cupertino
10300 Torre Avenue
Cupertino, CA 95014-3255
Telephone: 408-777-3228
C U P E RT I N O Fax: 408-777-3333
CONTRACTOR / SUBCONTRACTOR LIST ;
JOB ADDRESS: Z(ac r -Sri h 0°.
PERMIT #
OWNER'S NAME: P-4/'\ S v b ra yhot /1 M
PHONE #
GENERAL CONTRACTOR: CC)NS-(- •
BUSINESS LICENSE #
ADDRESS: 3cj15 .0 CA -1
CITY/ZIPCODE:
*Our municipal code requires all businesses working in the city to have a Baty of uupertm) Dusiness ncense.
NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE
GENERAL CONTRACTOR AND ALL SUBCONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO
BUSINESS LICENSE.
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following information:
/ Contractor Signature
Date
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
/ Contractor Signature
Date