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03060017 CITY OF CUPERTINO n,LQ0 ' A�IaBUILDINGDIVISION 1, 1,N o a PERMIT - . �t BUILDING ADDRESS: PERMIT NO-03060017 1648 PRIMROSE WY WNER'S NAME: PERMUT 1SU8A?T0 3 2 0 0 3 IVASHANKER SHANMUGAN NE; SANITARY NO. CONTROL NO. ARCHITECT/ENGINEER: - BUILDING PERMIT INFO BLDG ELECT PLUMB MECH 2p0 LICENSED CONTRACTOR'S DECLARATION Job Description v li 1 hereby affirm On,1 am licensed under provisions of Chapter 9("mmencing AZ1 with Section 7")of Division 3 of Ne Busients land Professions Code,an my license is j< mmnm4�ayeerrM ` NEW GAS LINE FOR COQKTOP T Z Llcenu CI Lia tC It'wyg Conr 'VI n/�undewns Mall D uRATION I 7 1 k.�/lrnd my plains he umtlpuhRra e orm 1 JUN 2003 �v Licenced Professional OWNER-BUILDER DECLARATION Clamor's p� I bomb,maso affirm That I 1 exempt from the Camracmo :Anycima.Lew for the BUILDING "CO following mason.permit 7031S,Business and Improve, dv Code:Any oily or county G $ which¢qui sa a pdmdo m cmmmcL ellen Impmw,de ural1 care pair any utemcm F S^ thtrmiucensed issuance. so r"Ravisiosof thrsuch e Consulates ofilem Law(ed sutemem that he is licensed pursuentmthe provisions of the Convmters lJanm law(Chapin9 Sq.Ft.Floor Area $41tiation Y (commencing with Section 7000)of Division]af site Businruand Rofeuinv CMe)ur 3 that he u eaempt theafrom and the basis for the alleged esempdm.My violation of Section 7031.5 by any applicant for a prmTil subjects the applicant to•civil penally of Occupancy Type not mom than Eve hundred dollars(SSW). ❑1,as owner of the property,at my croploymn whit wages as their gold compensation, will do the Wok.nd NeaWciam 1,W11nteadedm offered faraale(See.70",BullMgg Wr� C Ons and Professions Cade:The Cormselofs License law don rot apply m an owner of 3 01 — ROUGH lJ N property who Wildsor improves theran,and who doessuch wort himself orduough his ownemplowast.provided that such Mpmwmau are nvintsMM voffmal lvsaleIL 502 — FINAL PLUMBING ENERGY however,the building or Improvement is mid within oro year ofcompledon.0¢mover. 506 — GAS TEST buulll&'will have the wmen of phaving that he did nut build or improv for purpose of 507 — FINAL PLUMBING O I,as owner of the property,am"elusively contracting with llcalued contractors 10 commct the project(Sec.7064.Business and Profession Cade:)The Con uCteru U- _ cease law docs not apply in in minor of property who builds or Impmw Thereon,and. who contracts IN such projects with s cormorants)licensed puruunt in the Contractors License law. ❑L ern eastern under Sm. ,B&P C for this Manor wrier Data WORKER'S COMPENSATION DECLARATION(fm 1 hereby aa under penally of perjury,ON of live following dedu scion: I Nw and will msinWn a CutiOcau dfCove¢m celf--imam for WorkcraCmnpcn- aalion,an provided for by Sudan 3700 of the labor Cade,for On perfarmmed of the wort for which this permit is issued. ❑1 have and will maintain Workers Compensation Insurance,M required by Section 3700 of the labor Cade,for de perform rice of the wort for which this pevmil is Issued. My Workers Cam enoedan Insurancel�lcLrarie�erenld�Poliiry nu a Cam .c r CFt pus N'FR LO� R I CA (• ii" OM WORK S' COMPENSATION INSURANCE (rhiamcden need not be"mplcud If On permit Isfnroa hundrrAdolurs($101) or)ass.) I certify that in the performance of the work for which this permit is island,1 Mali not employ any person in any manner m an to become subject to the Workers'Compenldim, Laws of California.Dam Applicant NOTICE TO APPLICANT:If.after making Nis Cenibcam or Exemption.you Mould bocome subject in The Workers Comperum on previsions of the Labor Code,you mm 0 forthwith comply with such provisions or this permit Mall In deemed ranked. Il CONSTRUCTION LENDING AGENCY t -,44 1 hereby affirm Nat them is a contraction lending agency for the performance of pL a7 the work for which this permit u Wood(Side.3(1 Civ.C.) t[1 Q Lendcrs Name Z) z Lenders Address C)Q 1 ceniry that 1 have read this application and sum that the meow information is COMM I agree to comply with all city and county ominavea and state laws milling in 0 SV^ building consWetion,and hereby amhorim repressnulives of this city to enter upon On W above-mentioned property for inspection pugwms (We)agree to saw,indemnify and kap harmless the City of Cupertino again) A paq Ilabilitiea,judgmenu,cote and expenses which may in my way acerae against mid City �r V z in conaqucncc of the granting of Of,permit. ^' APPLICANT DERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date SOURCE R CATIONS, o Re-roofs Sigamu Applicant/ nova r Vale HAZARDOUS MATERIALS DISCLOSURE Type of Roof Will the applicant or future building notation,tram or handle ba ramous material "defined by the Cupertino Mun WI Code.Chapter 9.11,and the H"Ith and Safety We,sg tido 25531(07 All roofs shall be inspected prior to any roofing material being installed. Yea Will the applicant or future building oaupmt are cquipmem or devices which If a roof is installed without first obtaining an inspection,I agree to remove emit Nimmons air commons u deRncd by the Bay Area Air Quality Management all new materials for inspection. District? ❑Yea I haw,cad the heramvmsmateriebreyuimmenu under Chaper 6.95 of de Califon nla Fleaith@SafetyCode,SwU=25505.15533md25534.Lundeoumdthuirte Wilding dorsnot currene tly have a count,On,it u my terponsihilhy m madly the meopant of the .gpdnu which mus,Mmet prior uissuanccoreCcnip as rOccuanc Signature of Applicant Date o erarmuther agate OsloAll roof coverings to be Class"B"or better alo CITY OF CUPERTINO —) --o11 CU � PER PERMIT APPLICATION FORM t' IPIPN# Cj ^ O G �r Date: Building Address: / Owner's Name: ?<1- Phone#: 5i vash&m Icer Sham 7)149M 1041) z Contractor: License #: Contact: Cupertino Business License#: Taec S Building Permit Info: -- \ Bldg ❑ Elect ❑ Plu b Mech Job Description: �1_�y Residential ❑ 1 tV "T t� ' ^"" ommerc�al Sq.Ft. Floor Area: $/Sq.Ft.: Cost of Project: Occupancy Group: Type of Construction: Quantity Fee ID Fee Description Fee Group BAPPLOTHER Other Appliances MECHANICAL BBLDGFEE Bldg Permits . foot BUILDING BBOILERI Boiler<= 100,000 Btu MECHANICAL BBOILER2 Boiler> 100K to 500K Btu MECHANICAL BBOILER3 Boiler> 500K to 1M Btu MECHANICAL BBOILER4 Boiler> 1M to 1.75 M Btu MECHANICAL BBOILER5 Boiler> 1.75MBtu MECHANICAL BCONSTAX Construction Tax BUILDING BCONSTAX Ind/Off/Comm/Quasi BUILDING BCONSTAXBQ Con. Tax for BQ Zone BUILDING BCONSTAXH Hotel and Motel BUILDING BCONSTAXR Constax—Resi/Mobile BUILDING BELEC1000 Elec 600V <= 1000A ELECTRICAL BELEC1001 Elec 600V> 1000A ELECTRICAL BELEC200 Elec Svcs 600V <= 200A ELECTRICAL BENERGY Energy BUILDING BENERGYADD Energy Add Multi BUILDING BINVESTIGA Investigation fee BUILDING BMITIGATC Comm. Housing Mit. Fee BUILDING 1 of 3 - CITY OF CUPERTINO CITY0 PERMIT APPLICATION FORM CUPEkTINO Quantity Fee ID Fee Description Fee Group BMITIGATR Res. Housing Mit Fee BUILDING BMNEWMULTI New Multi-Family Res MECHANICAL BMNEWSF&2F New Sf&2F Res Bldgs MECHANICAL BNEWMULTI Multifami] Res ELECTRICAL BNUCOMME New Comm Electric ELECTRICAL BNUCOMMM New Comm Mechanical MECHANICAL BNUCOMMP New Comm Plumb PLUMBING BNUMULTI New Multifamily Res PLUMBING BNUSFD New Sin le Family Res BUILDING BOVERTIME Inspection Overtime BUILDING BPBACKFLOW Atmospheric Vacuum PLUMBING BPCESSPOOL Cesspool PLUMBING BPERMFEE Bldg Permit Fees BUILDING BPFIXTURE Pblg Fixture PLUMBING BPGAS Gas Piping System Fee PLUMBING BPINTERCEP Ind Waste Interceptor PLUMBING BPLANCHK Plan Check Fee BUILDING BPLANCKADD Plan Check Add Multi BUILDING BPLANCKREP Plan Check Repeat Fee BUILDING BPREPIPE Re i e Of Fixtures PLUMBING BPSEWAGE Sewage Disposal PLUMBING BPSEWER Sewers PLUMBING BPSPRINK Lawn S rinkler/Backflo PLUMBING BPSTORM Storm/Rain Water PLUMBING BPTRAP Kitchen Trap PLUMBING BPVENT Alt of Drain &Vent PLUMBING BPWATER Install/Alter Water Pie PLUMBING BPWHEATER Water HeaterNent PLUMBING BPWSVCS Main Water Service PLUMBING BREINSPECT Reinspection Fee BUILDING BREMACOVER A/C Unit> 10,000 cfm MECHANICAL BREMARUTAN A/C Units <= 10,000 cfm MECHANICAL BREMAPPLI Appliance Install MECHANICAL BREMBUSWAY Remodel Busways ELECTRICAL BREMFDtT Lighting Fixtures ELECTRICAL BREMFURN Relocation of Fumace MECHANICAL BREMFURNOV Relo Furnace> l OK btu MECHANICAL BREMHEAT Heater Installation MECHANICAL BREMINHOOD I Installation of Hood MECHANICAL BREMMISC Misc Apparatus ELECTRICAL BREMNRAPP Rem Non-Res Appliance ELECTRICAL BREMPOLE Pole/Platform Fixture ELECTRICAL 2 of 3 CITY OF CUPERTINO CITY OFA PERMIT APPLICATION FORM ' CUPERTINO Quantity Fee ID Fee Description Fee Group BREMPOWER Power Device/Apparatus ELECTRICAL BREMRECEPT Rc tl, Switch &Outlets ELECTRICAL BREMRELOCA Relocation of Hood MECHANICAL BREMREPALT Repair/Alter Heating MECHANICAL BREMRESAPP Remodel Res Appliance ELECTRICAL BREMSIGNAD Rmdl Signs Add Branch ELECTRICAL BREMSIGNS Remodel Signs,Marquee ELECTRICAL BREMTHEATR Theatrical Lighting Fix ELECTRICAL BREMVENFAN Vent Fan Single Duct MECHANICAL BREMVENSYS Ventilation Systems MECHANICAL BSCBLVD Scb Specific Plan BUILDING BSEISMICOM Seismic Commercial BUILDING BSEISMICRE Seismic Fee Res BUILDING BSPECIAL Special Insection BUILDING BSWIM Swimming Pool BUILDING BTEMP Temporary Power ELECTRICAL BTEMPPERM Temporary Bldg Permit BUILDING BTEMPSVCS Temp Dist Svcs ELECTRICAL BUSLIC Business License BUILDING ELECTRIC Electrical sq foot ELECTRICAL EPERMITFEE Elec Permit Issuance ELECTRICAL MPERMFEE Mechanicals . foot MECHANICAL MPERMITFEE Mech Permit Issuance MECHANICAL PPERMITFEE Plumbing Permit Issuance PLUMBING PPLBG Plumbing Fee sq foot PLUMBING ZADDCHG Address Chane 'BUILDING 3 of 3