10100024CITY OF CUPERTINO BUILDING PERMIT I
BUILDING ADDRESS: 21618 ROSARIO AVE
'ER'S NAME: MOHAN PARTHASARATHY
OWNER'S PHONE: 4088131500
❑ LICENSED CONTRACTOR'S DECLARATION
License Class Lic. #
Contractor
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.
Date
[9� 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).
CONTRACTOR: MOHAN
PERMIT NO: 10100024
PARTI IASARATHY
21618 itOSARIO AVE
DATE ISSUED: 10/04/2010
CUPE ?.TING, CA 95014
PHONE NO:
r— r PLUMB
BUILDING PERMIT INFO: BLDG ELECT
f— RESIDENTIAL F COMMERCIAL
MECH
JOB . )ESCRIPTION: REPLACE GAS FURNACE
Sq. F1 Floor Area:
Valuation: $4000
APN Vumber: 35619015.00
Occupancy Type:
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
the above mentioned property for inspection purposes. (We) agree to save
mnify 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. f go L-
Signature Date / o Ll
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 D YS FROM L CALLED INSPECTION.
/ d / 0 Date:
Issue d by:
RE -ROOFS:
All r< ofs 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
inspe -,tion.
Sign: lure of Applicant: Date:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
HAZARDOUS MATERIALS DISCLOSURE
I ha -e read the hazardous materials requirements under Chapter 6.95 of the
Cali'ornia Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain
com 3liance with the Cupertino Municipal Code, Chapter 9.12 and the Health &
Safety Code, Section 25532(a) should I store or handle hazardous material.
Add itionally, should I use equipment or devices which emit hazardous air
cont aminants as defined by the Bay Area Air Quality Management District I will
mail lain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
Hea ith & Safety Code, Sections 25505, 25533, and 25534.
Owner or aut nt:
- Date:
CONSTRUCTION LENDING AGENCY
I he -eby affirm that there is a construction lending agency for the performance of work's
for, vhich this permit is issued (Sec. 3097, Civ C.)
Len der's Name
Len der's
ARCHITECT'S DECLARATION
I ur derstand my plans shall be used as public records.
Lic -nsed Professional
CITY OF CU PERTINO
FFF. FgTIMATOR — BUILDING DIVISION
APPLIANCE / EQUIP TYPE
ADDRESS: 21618 rosario ave
DATE: 10/04/2010
REVIEWED BY: larry s
UNITS
APN:
BP#:
*VALUATION: $4,000
xPERMIT TYPE: Mechanical Permit
PLAN C1-IECK TYPE: Alteration / Addition / Repair
PRIMARY
USE: SFD or Duplex
,1
,, r> „�
PENTAMATION FURN/AC
PERMIT TYPE:
WORK
replace gas furnace
SCOPE
APPLIANCE / EQUIP TYPE
FEE ID
QTY/FEE
QTY
UNITS
BP FEES
Furnace, Forced -Air
1MFR=<100
jest'
Li�`'.,LD
1
#
$126
flct-lnil Fc c.
PME Unit Fee:
$126.00
PME Permit Fee:
$42.00
F71Work
Without Permit? 0 Yes E) No
$0.00
TOTALS:
Travel Documentation Fee: 1TRA VDOC
$126.00
Strong Motion Fee:
TL.h--I . " fho nvnilahle and are only an estimate. Contact the Dept for addn'l info.
l 1V!!i. 1-G
FEE ITEMS (Fee Resolution 09-051 E/f. '/L 10)
Mech. Plan Check Rolhrs $0.00
QTY/FEE
MISC ITEMS
FMech. Permit Fee: IMPERMIT
Other Mech. Insp. 0.0 hrs $42.00
F-1
jest'
Li�`'.,LD
PME Plan Check:
$0.00
TL.h--I . " fho nvnilahle and are only an estimate. Contact the Dept for addn'l info.
l 1V!!i. 1-G
FEE ITEMS (Fee Resolution 09-051 E/f. '/L 10)
FEE
QTY/FEE
MISC ITEMS
slip/"[ 1'(. [cc
F-1
PME Plan Check:
$0.00
flct-lnil Fc c.
PME Unit Fee:
$126.00
PME Permit Fee:
$42.00
F71Work
Without Permit? 0 Yes E) No
$0.00
Travel Documentation Fee: 1TRA VDOC
$42.00
Strong Motion Fee:
$0.5C
Select an Administrative Item
Bldp Stds Commission Fee: 1BCBSC
$1.0(
SUBTOTALS:
$211.50
$0.00 TOTAL FEE:
$211.50
Revised: 9/29/2010
5 ITEMS OF 5
CITY OF CUPE RTINO
PERMIT RECEIPT
Sec: Twp: Rng: Sub: Blk: Lct:
APN ........: 35619015.00
DATE ISSUED.......: 10/04/2010
RECEIPT #......... BS000011629
REFERENCE ID # 10100024
SITE ADDRESS 21618 POSARIO AVE
SUBDIVISION ......
CITY CUPERT=:NO
IMPACT AREA ......
OWNER MOHAN ]?ARTHASARATHY
ADDRESS . 21618 ROSARIO AVE
CITY/STATE/ZIP CUPERTCNO, CA 95014
RECEIVED FROM ....: MOHAN ?ARTHASARATHY
CONTRACTOR LIC # *OWNER*
COMPANY MOHAN PARTHASARATHY
ADDRESS . 21618 ROSARIO AVE
CITY/STATE/ZIP CUPERTINO, CA 95014
TELEPHONE .........
OPERATOR: patg
COPY # : 1
FEE ID
UNIT
QUANTITY
AMOUNT
PD -TO -DT
------ ---
THIS REC
----
--NEW-BAL-
----------
1BCBSC
1BSEISMICR
1MFR=<100
1MPERMITFE
1TRAVDOC
-------------
VALUATION
VALUATION
UNITS
FLAT RATE
FLAT RATE
----------
4,000.00
4,000.00
1.00
1.00
1.00
----------
1.00
0.50
126.00
42.00
42.00
0.00
0.00
0.00
0.00
0.00
----------
1.00
0.50
126.00
42.00
42.00
----------
0.0
0.00
0.00
0.00
------0_00
TOTAL PERMIT
----------
1.11.50
0.00
211.50
0.00
METHOD OF PAYMENT
-----------------
CREDIT CARD
TOTAL RECEIPT :
AMOUNT
---------------
211.50
---------------
211.50
VOICE ID DESCRIPTION
-------- --------------------
505 FINAL ELECTRICAL
508 FINAL MECHANICAL
REFERENCE NUMBER
---------------------
Mc:
VOICE ID DESCRIPTION
-------- ------------------------
507 FINAL PLUMBING
CUPERTINO
OWNER -BUILDER DISCLOSiJRE FORM
COMMUNITY DEVELOPMENT DEPARTMEN-' - BUILDING DIVISION
10300 TORRE AVENUE - CUPERTINO, CA 9:014-3255
(408) 777-3228 • FAX (408) 777-3333 • buildinci(a)cupertino.ora
Dear Property Owner(s):
An application for a building permit has been submitted in your n 3me listing yourself as the builder of the property
improvements specified at:
SIT ADDRESS APN IBPVD/000
L� I
OWNER NAME
kA,0 "
DESCRIPTION OF
7
OWNER ADDRES:)
CQ.
We are providing you with an Owner -Builder Acknowledgment a id Information Verification Form to make you aware of
your responsibilities and possible risk you may incur by having this permit issued in your name as the Owner -Builder. We
will not issue a building permit until you have read, initialed your understanding of each provision, signed, and
returned this form to us at our official address indicated. Ail agent of the owner cannot execute this notice unless
you, the property owner, obtain the prior approval of the permitting authority.
OWNER'S ACKNOWLEDGMENT AND VERIFICATION OF INFORMATION
(DIRECTIONS: Please read and initial each statement below to signify you understand or verify this information)
bt1. I understand a frequent practice of unlicensed perso-is is to have the property owner obtain an "Owner -
Builder' building permit that erroneously implies that the property owner is providing his or her own labor and material
personally. I, as an Owner -Builder, may be held liable and sibject to serious financial risk for any injuries sustained by
an unlicensed person and his or her employees while working on my property. My homeowner's insurance may not
provide coverage for those injuries. I am willfully acting as a i Owner -Builder and am aware of the limits of my
insurance coverage for injuries to workers on my property.
UtA-2. I understand building permits are not required to be Signed by property owners unless they are responsible for
the construction and are not hiring a licensed Contractor to assume this responsibility.
bA-
3. I understand as an "Owner -Builder" I am the respon:;ible party of record on the permit. I understand that I may
protect myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her
name instead of my own.
JA4. I understand Contractors are required by law to be licensed and bonded in California and to list their license
numbers on permits and contracts.
5. I understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the
total value of my construction is at least five hundred dollar:; ($500), including labor and materials, I may be
considered an "employe" under state and federal law.
_Lo6. I understand if I am considered an "employer" under state and federal law, I must register with the state and
federal government, withhold payroll taxes, provide worker:' compensation disability insurance, and contribute to
unemployment compensation for each "employee." I also understand my failure to abide by these laws may subject
me to serious financial risk.
L�_7. I understand under California Contractors' State Licanse Law, an Owner -Builder who builds single-family
residential structures cannot legally build them with the intent to offer them for sale, unless all work is performed by
licensed subcontractors and the number of structures does not exceed four within any calendar year, or all of the work
is performed under contract with a licensed general building Contractor.
tt^ 8. 1 understand as an Owner -Builder if I sell the property for which this permit is issued, I may be held liable for
any financial or personal injuries sustained by any subsequent owner(s) that result from any latent construction
defects in the workmanship or materials.
OwnerBuilderForm 2010.doc revised 04114110
9. I understand I may obtain more information regarding my obligations as an "employer" from the Internal
venue Service, the United States Small Business Administration, the California Department of Benefit Payments,
and the California Division of Industrial Accidents. I also undo rstand I may contact the California Contractors' State
License Board (CSLB) at 1-800-321-CSLB (2752) or www.cs b.ca.gov for more information about licensed
contractors.
6L�10. 1 am aware of and consent to an Owner -Builder building permit applied for in my name, and understand that I
am the party legally and financially responsible for proposed :onstruction activity at the site address listed above.
I� 11.1 agree that, as the party legally and financially responsible for this proposed construction activity, I will abide
by all applicable laws and requirements that govern Owner-Euilders as well as employers.
K12. 1 agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the
information I have provided on this form. Licensed contractors are regulated by laws designed to protect the public. If
you contract with someone who does not have a license, the Contractors' State License Board may be unable to
assist you with any financial loss you may sustain as a result of a complaint. Your only remedy against unlicensed
Contractors may be in civil court. It is also important for you lo understand that if an unlicensed Contractor or
employee of that individual or firm is injured while working or your property, you may be held liable for damages. If
you obtain a permit as Owner -Builder and wish to hire Contractors, you will be responsible for verifying whether or not
those Contractors are properly licensed and the status of their workers' compensation insurance coverage.
CONSTRUCTION LENDING AGENCY
(DIRECTIONS: Please complete the following construction lendi ig agency information.)
I hereby affirm that there is a construction lending agency for tl-e performance of the work for which this permit is issued
(Sec 3097 Civ.)
Lender Name:
Lender Adc ress:
Before a building permit can be issued, this form must be completed and signed by the property owner and
returned to the agency responsible for issuing the permit. Note: A copy of the property owner's driver's license,
form notarization, or other verification acceptable to the city may be required to be presented when the permit is issued
to veriFy the property owner's signature.
Property Owner's Signature: Date: 0
b
---------------------------------------------------------------------------------------------------------------------------------------------
(NOTE: The following Authorization Form is required to be completed by the property owner only when designating an
agent of the property owner to apply for a construction permit fo � the Owner -Builder).
AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF
Excluding the Notice to Property Owner, the execution of which I understand is my personal responsibility, I hereby
authorize the following person(s) to act as my agent(s) to apply For, sign, and file the documents necessary to obtain an
Owner -Builder Permit for my project. C_ e_
Scope of Construction Project (or Description of Work):
Project Location or Address: 2 U sw-:I� Cy r�k
Name of Authorized Agent:'&,bV m a S Tel No
Address of Authorized Agent: S S .� a vve H Y1 h �"
I declare under penalty of perjury that I am the property owner f or the address listed above and I personally filled out the
above information and certify its accuracy. Note: A copy of the property owner's driver's license, form notarization, or other
verification acceptable to the city may be required to be presen `ed when the permit is issued to verify the property owner's
signature.
Property Owner's Signature: U' Date: B ��
OwnelBuilderForm 2010.doe revised 04/14110
acloF
CUPEkTINO
CITY OF CUPERTINO
FURNACE/AC
PERNUT APPLICATION FORM
APN # (0 19 () I:
Date:
Building Address: 2- 6 , g �o S y,0 A �/�
�� P � Q. -t 1 N o
�
Owner's Name:
Phone #: 3
T � S1A��n 7
Contractor: -
Phone #:
Fax #:
Contractor License #:
Cupertino Business License #:
Contact:
Phone #:
Fax #:
Building Permit Info:
Elect ❑ Plumb ❑ Mech ❑
Residential Commercial
Job Description:
9_c0o� e (S\ t
For Residential Installations:
Attic El1 " floor ❑ 2nd floor ❑
Adhere to minimum setback requirement ❑
For Commercial Installations:
Replacement same weight E-,-- Additional weight (structural calcs) ❑
Structural Calculations required for new installation []
New installation Planning Approval Required ❑
Cost of Project: Type of Construction (Usage Class):
� 4e 10,0
Y
Strapped El On Platform 0 Bonded New Location Replacement
Project Size: Ex ress ❑ Standard ❑ Large ❑ Major ❑
Valuation:
Green Building: Please complete relevant portion of the Green Building Checklist & attach it to the
ATAI\AATfAT nr if .2nnlioahla inelntlp in nlan CPt & the rh P.Pt indo-y-
--r-r- ---- -- — --rr a
Revised 01/07/09
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 22577 SAN JUAN RD
CONTRACTOR: EISENBACH
PERMIT NO: 10100063
CONS' -RUCTION
OWNER'S NAME: MICHAEL 1 DHUEY
1130 C HERRYVIEW LN
DATE ISSUED: 10/07/2010
e,R'S PHONE: 4085053226
SAN JOSE, CA 95118
PHONE NO: (408) 265-5925
❑ LICENSED CONTRACTOR'S DECLARATION
F (—
BUIL ��ING PERMIT INFO: BLDG ELECT PLUMB
License Class 0—/ Lic. # �
r— r
r
Contractor �%, .]
MECH RESIDENTIAL COMMERCIAL
1 hereby affirm that 1 am licensed under the provisions of Chapter 9
JOB DESCRIPTION: BATH REMODEL NON-STRUCTURAL INCLUDE
(commencing with Section 7000) of Division 3 of the Business & Professions
MECH, ELECT/PLMBNG
REPLACE WATER HEATER, ADD 220 VOLT CIRCUIT AT
Code and that my license is in full force and effect.
1 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 pennit is issued.
I have and will maintain Worker's Compensation Insurance, as provided for by
Sq. Ft Floor Area:
Valuation: $20000
Section 3700 of the Labor Code, for the performance of the work for which this
permit is issued.
APN I` umber: 34217084.00
Occupancy Type:
APPLICANT CERTIFICATION
1 certify that 1 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
PERMIT EXPIRES IF WORK IS NOT STARTED
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
costs, and expenses which may accrue against said C' y in consequence of the
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
granting of this permit. Additionally, the applica nderstands and will comply
1110 DAYS FROM LAST CALLED INSPECTION.
with all non- e re ions er the ertino Municipal Code, Section
9.18.
Issuec by: Date:
Signature Date /y— 7—/c►
G OWNER -BUILDER DECLARATION
RE -ROOFS:
1 hereby affirm that 1 am exempt from the Contractor's License Law for one of
All roofs shall be inspected prior to any roofing material being installed. If a roof is
the following two reasons:
installeJ without first obtaining an inspection, I agree to remove all new materials for
1, as owner of the property, or my employees with wages as their sole compensation,
inspect ion.
will do the work, and the structure is not intended or offered for sale (Sec. 7044,
Business & Professions Code)
Signatt re of Applicant: Date:
1, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec.7044, Business & Professions Code).
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
1 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
HAZARDOUS MATERIALS DISCLOSURE
Compensation, as provided for by Section 3700 of the Labor Code, for the
I have read the hazardous materials requirements under Chapter 6.95 of the
performance of the work for which this permit is issued.
Califon nia Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain
I have and will maintain Worker's Compensation Insurance, as provided for by
compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health &
Section 3700 of the Labor Code, for the performance of the work for which this
Safety Code, Section 25532(a) should 1 store or handle hazardous material.
permit is issued.
Additi,mally, should I use equipment or devices which emit hazardous air
contaminants as defined by the Bay Area Air Quality Management District I will
1 certify that in the performance of the work for which this permit is issued, 1 shall
maintain compliance with the Cupe ino Municipal Code, Chapter 9.12 and the
not employ any person in any manner so as to become subject to the Worker's
Health & Safety Co ons 05, 25533, and 25534.
Compensation laws of California. If, after making this certificate of exemption, I
'_ �! �
th age
become subject to the Worker's Compensation provisions of the Labor Code, 1 must
mer or zfert
forthwith comply with such provisions or this permit shall be deemed revoked.
Date:
APPLICANT CERTIFICATION
CONSTRUCTION LENDING AGENCY
I certify that I have read this application and state that the above information is
I hereb i affirm that there is a construction lending agency for the performance of work's
correct. I agree to comply with all city and county ordinances and state laws relating
for which this permit is issued (Sec. 3097, Civ C.)
to building construction, and hereby authorize representatives of this city to enter
Lender's Name
upon the above mentioned property for inspection purposes. (We) agree to save
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
Lender's Address
C ind expenses which may accrue against said City in consequence of the
g. ag of this permit. Additionally, the applicant understands and will comply
with all non -point source regulations per the Cupertino Municipal Code, Section
ARCHITECT'S DECLARATION
9.18.
1 undertand my plans shall be used as public records.
Signature Date
Licens A Professional