15050103 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10781 JOHNSON AVE CONTRACTOR �A. ht"Y 1 PERMIT NO: 15050103
OWNER'S NAME: RAYAPATI VENKATAPATHI N AND VIJAYAS -fes DATE ISSUED:05/18/2015
OWNER'S PHONE: 4088068260 /�t9 Cts PHONE NO:
LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL COMMERCIAL
RELOCATE& REMODEL(E)KITCHEN(257 S.F.),
License Classy Lic.# 3_ % REMODEL
Contractor % Date
1 k t (E)LIVING ROOM(400 S.F.)&REPLACE 3 WINDOWS IN
(E)OPENINGS
I hereby affirm that I am licensed under t e 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. Sq.Ft Floor Area: Valuation:$20000
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 APN Number:37531060.00 Occupancy Type:
permit is issued.
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED
correct.l agree to comply with all city and county ordinances and state laws relating WITHIN 180 DAYS OF PERMIT ISSUANCE OR
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save +D INSPECTIO
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 Is Date:
with all non-point source regulations per the Cupertino Municipal Code,Section
9 18.
r� RE-ROOFS:
Signature Date J 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.
❑ OWNER-BUILDER DECLARATION
Signature of Applicant: Date:
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
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 HAZARDOUS MATERIALS DISCLOSURE
construct the project(Sec.7044,Business&Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the
California Health&Safety Code,Sections 25505,25533,and 25534. I will
1 hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
declarations: Health&Safety Code,Section 25532(a)should I store or handle hazardous
I have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally,should I use equipment or devices which emit hazardous
Compensation,as provided for by Section 3700 of the Labor Code,for the air contaminants as defined by the Bay Area Air Quality Management District I
performance of the work for which this permit is issued. will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sections 25505,2533,and 25534.
Section 3700 of the Labor Code,for the performance of the work for which this _V)
permit is issued. Owner or authorized agent: A/ �� Date: 11
I certify that in the performance of the work for which this permit is issued,I shall 7
not employ any person in any manner so as to become subject to the Worker's
Compensation laws of Califomia. If,after making this certificate of exemption,I CONSTRUCTION LENDING AGENCY
become subject to the Worker's Compensation provisions of the Labor Code,I must I hereby affirm that there is a construction lending agency for the performance of
forthwith comply with such provisions or this permit shall be deemed revoked. work's for which this permit is issued(Sec.3097,Civ C.)
Lender's Name
APPLICANT CERTIFICATION Lender's Address
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 ARCHITECT'S DECLARATION
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the 1 understand my plans shall be used as public records.
granting of this permit.Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section Licensed Professional
9 18.
Signature Date
I.
CONSTRUCTION PERMIT APPLICATION
o �
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION O
CUPERTINO
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 O
(408)777-3228 • FAX(408)777-3333•building(ci�,cupertino.org \
❑NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION/Ti ❑ REVISION/D
E
FERRED ORIGINAL PERMIT/9
PROJECf ADDRESS (� `7 C+ l/
APN# 2 1 Z /�I /�, /1
OWNER NAME r PHONE % f E-MAIL i (� LLLIII
,, E ',�
STREET ADDRESS0 7G ` I CITY, STATE,ZIP / D n(+^�/ FAX
CONTACT NAME ILIA na�� Y PHONE ,J •]E-MAIL
STREET ADDRESS( CITY,STATE,, ZIP ( /� FAX
1:1 OWNER ElIOWNER-B ER ❑ OIVNER AGENT ❑ CONTRACTOR CONrR4CTOR AGENT 13A]LCHITECT El ENGINEER 11DEVELOPER 13TENANr
CONTRACTOR N I_ ( / LICENSE NUMBER 2 I/'_ ,f0 LICENSE TYPE BUS.LIC#
COMPANY NAME E-MAIL J FAX
STREET ADDRESS O (' n
ACITY,STATE,ZIP �i n ( � PHO 'Ii
ARCHITECT/ENGINEER NAME > V LICENSE NUMBER lY BUS.LIC# r
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
DESCRIPTION OF WORK
� 1
EXISTING USE PROPOSED USE CONSTR TYPE I #STORIES
, USE TYPE OCC. SQ.FT. VALUATION(S)
MSTG NEW FLOOR DEMO TOTAL
AREA AREA AREA NET AREA
BATHROOM KITCHEN OTHER ///
REMODEL AREA REMODEL AREA J-"F�('`•� 11 REMODEL AREA n
PORCH AREA DECK AREA TOTAL DECK/PORCH AREA GARAGE AREA: LJ DETACH
❑ATTACH
K DWELLING UNITS: IS A SECOND UNIT El YES SECONDSTORY E]YES
BEING ADDED? NO ADDITION? []NO
PRE-APPLICATION []YES IF YES,PROVIDE COPY OF IS THE BLDG AN OTAL VALUATION,
PLANNING APPL N ❑NO PLANNING APPROVAL LETTER EICHLER HONIE? z cn /Y/ho
By my signature below,I certify to each of the following: I am the property owner or autho ent to a th perry owner's I have read this
application and the information I have provided is correct. I have read the Description of Work and ve ' curate. I agree to comply wit applicable local
ordinances and state laws relating to building construction. I authorize representatives of Cupertino to enter the above-identified property for inspection purposes.
Signature of Applicant/Agent: aklA Date:
SUPPLEMENTAL INFORMATION REQUIRED
T o T >' .. f a =s•'� 'YF.6, hI^x}SJ I`5 i ;
New SFD or Multifamily dWellin�s: Apply for demolition permit for � �
❑ O VER TH7<i O' tN ER tw .tiBU.Q.DING PLAN REVIEW:c
existing buildings. Demolition permit is required prior to issuance of buildingk _
a o() II 9 IT yMpi
permit for new building ❑ EXP � wAtlr> GmL�Aiv`T2EVIEw
#kf4lz t ,.ar
i.
_Commercial Bldgs: Provide a completed Hazardous Materials Disclosure C1 sTAtvnAxD t Q�rt�BLlcwox�cs fits h
x>r
form if any Hazardous Materials are being used as part of this project. «t •�
�rISt1RGF� SS�� $ � DE>'x� a � "
_Copy of Planning Approval Letter or Meeting With Planning prior to zarkr`� I�€ r*j}
,i�IA.rOR. €7t. rir�-�.- ' t��rSYVTfA"f;.Y SEw�ER�DISTRIC"k� 4
submittal of Building Permit application. A �ft�
�42 .IE.) fj "i,-.:a".1
,..�k EI�'Y7ItONMENTALHEAli.TH Y
BIdgApp_2011.doc revised 06/21/11
CITY OF CUPERTINO
FEE ESTIMATOR- BUILDING DIVISION
ADDRESS: 10781 JOHNSON AVE DATE: 05/18/2015 REVIEWED BY: MELISSA
APN: 375 31 060 BP#: -VALUATION: 1$20,000
*PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration/Repair
PRIMARY SFD or Duplex PENTAMATION 1R3SFDRE
USE: PERMIT TYPE: i
WORK RELOCATE & REMODEL E KITCHEN 257 S.F.), REMODEL E LIVING ROOM 400 S.F. &
SCOPE REPLACE 3 WINDOWS IN (E) OPENINGS
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a
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F1,tc:h. P,>rn,rl Fce: Plunlh,1'cr,,,,'rir l Esc: Pw-m;/Pcr'
Insp, 01ile,'Pht+„0 Insp Other/loc. Msfa. Lj
bhzc/r. fns".). Fe', 1'11amh. hasp. Fe": L,lec:'. Msp. Pee:
NOTE: This estimate does not include fees due to other Departments(i.e.Planning,Public Works,Fire,Sanitary Sewer District,School
District,eta). Thesefees are based on the prelimina information available and are only an estimate. Contact the De t or addn'l info.
FEE ITEMS (Fee Resolution 11-053 Eff.' 7/1/13) FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 257 s.f. Remodel,Kitchen(<=300 sf)
Suppl. PC Fee: (F) Reg. 0 OT 0,0 hrs $0.00 $645.00 IREMRESKIT
PME Plan Check: $0.00 400 s.f. Remodel, Other
Permit Fee: $0.00 $503.00 IREMRESOTH
Suppl. Insp. Fee.-E) Reg. Q OTO p hrs $0.00 0 # Window/Sliding Glass Door
PME Unit Fee: $0.00 $431.00 1 WINREP Replacement
PME Permit Fee: $0.00
<_'uttsircution :i crr:
4t:]i"r21lt1,CltYXti1'cJ
Work Without Permit? 0 Yes (F) No $0.00 E)
Advanced Planning Fee: $0.00 Select a Non-Residential 0
Building or Structure
'1'rui�<�1 IJrx•rrtncnluiinn T���:�.>': �
Strom Motion Fee: IRSEISMICR $2.60 Select an Administrative Item
Blde Stds Commission Fee: IBCBSC $1.00
3.60 $1$1,582.60
Revised: 05/07/2015