12060172 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10441 STOKES AVE CONTRACTOR: DEEPAK AGRAWAL PERMIT NO: 12060172
OWNER'S NAME: DEEPAK AGRAWAL 10441 STOKES AVE DATE ISSUED:06/28/2012
OWNER'SPIIONE: 4084214712 CUPERTINO.CA 95014 PIIONF.NO:
❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL COMMF,RCIAI.
11
License Class Lic.q REMODEL BATH 80 SQ FT-CHANGE TUB TO
WHIRLPOOL,
Contractor Date SINGLE SINK TO DOUBLE,TILE AND CABINETS
I hereby affirm that 1 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.
1 hereby affirm under penally 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.F'1 Floor Area: Valuation:$3500
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:32647030.00 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. I agree to comply with all city and county ordinances and stale 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 180 DAYS FROM LAST CALLED INSPECTION.
indemnify and keep harmless the City of Cupertino against liabilities,judgments, I
costs,and expenses which may accrue against said City in consequence of the ( J
granting of this permit. Additionally,the applicant understands and will comply Issued by: 1�to �— Dale:(,4 '
with all non-point source regulations per the Cupertino Municipal Code,Section
9A& V
Rb:ROOFS:
Signature Date All roofs shall be inspected prior to any rooting material being installed. If a roof is
installed without first obtaining an inspection,I agree to remove all new materials for
inspection.
OWNEWBUILDF.R DECLARATION
Signature of Applicant: Date:
I hereby affirm that I am exempt from the Contractor's License Law for one or
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)
I,M owner of(he property,am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE
construct the project(Sec.7044,Business&Professions Code). 1 have read the hazardous materials requirements under Chapter 6.95 of the
California Ilealth&Safety Code,Sections 25505,25533,and 25534. 1 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: Ilealth&Safety Code,Section 25532(1)should I store or handle hazardous
I have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally,should 1 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
performance oflhe work for which this permit is issued. will maintain compliance with the Cupertino Municipal Cade,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Ilealth&Safety Code,Sections 25505,25533,and 25534.
Section 3700 of the Labor Code,for the performance of the work for which this 5 W"7 n U1 I L
permit is issued Owner or authorized agent:� � Date:
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 Califomia. If,after making this certificate of exemption,1 CONSTRUCTION LENDING AC.FNCI'
become subject to the Worker's Compensation provisions of the Labor Code,1 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. works for which this permit is issued(Sec.3097,Civ C.)
Lender's Name
APPLICANT CERTIFICATION Lender's Address
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 herebyauthorize 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, ARCHITECT'S DECLARATION
costs,and expenses which may accrue against said City in consequence of the I 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.
51y1u. 12
Signature l � Date
CITY OF CUPERTINO
FEE ESTIMATOR— BUILDING DIVISION
:121 ADDRESS: 10441 Stokes Ave. DATE: 06/28/2012 REVIEWED BY: jsg
APN: BP#: 'VALUATION: $3,500
^PERMIT TYPE: Minor Building Permit PLAN CHECK TYPE: Remodel, Kitchen (300 s.f. max)
PRIMARY Residential PENTAMATION 1R3SFDREM
USE: PERMIT TYPE:
WORK Bath remodel instal 'acuzzi two sinks some elec and plumb
SCOPE
FEE ID FLR AREA
s.f.
1REM E KI 80
11,;:1r_ Ylun i'h•;r-k Mani,, l'lun Owc6 /]ca. 1'Imr Chc,:k
;Ll.-rlr. ]'.•,nrit Iii," l'bunl+. 1'crmil l4•.:: P;l,;r. I'dr'orir l'r.:
i
Odic' ,t/r.'h. Lee/, Otho Phmrh/nsp_ Li Udm,Elan. Lop.
.Il"h, In•p. I-n !'boob. Lop. Ft". F!r•r_Iny. 14r:
NOTE: This estimate does not include fees due to other Departments(i.e. Planning, Public ;Yorks, 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 (Fcc Resohnion 11-053 ER' 711111) FEE QTY/FEE MISC ITEMS
Ph 117 Clre(k I A
Nrrppl. P( Fe,,
IVl n6.;':1-lr,,h./isle.:
Permit Fee: $588.00
Cuppi. hrsp /2v
/'/111116_;Mc,h/Flee
mrh.::l1CrhJ1Jc( IY)milFcc
i",oulrur lion T,r.r:
.I,.h;imi,rn,rlirC h'Cc_
Work Without Permit? O Yes 0 No $0.00
'kh'Jnr CtlPhumiri,, hires:
71-alrc/ 1?ormu, 111nliun (',res.
Strong Motion Fee: IBSEISM/CB $0.50 Select an Administrative Item
131da Stds Commission Fee: IBCBSC $1.00
SUBTOTALS: $589.50 $0.0011 TOTAL FEE: $589.50
Revised: 06/30/2012
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OFFRCEtpl Ul1
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OWNEWBUILDER DISCLOSURE FORM
I
COMMUNITY DEVELOPMENT DEPARTMENT"BUILDING DIVISION
10300,TORRE AVENUE.,CUPERTINO,CA 95014-3255
CUPERTINO (408)7Tf-3228•FAX(408)777-3333"buildlnardCuoertino.oro
Dear Property Owner(s):
An application for a building permit has been submitted in your name listing yourself as the builder of the property
improvements specified at:
SITE ADDRESS [0Z1Zj1 S;TOKfiS i}.V)ZlcuPs a"" APN aPq
1 OWNER NAME Fah PAK A , iAH1AAL OWNER ADDRESS
I DESCRIPTION OF WORK: CHAN641G BATH -TV13 TO WHIRLP00L [HfVIV4E S/N/c TO D0Vr3i—C
\ 51N11 TILES AND I CAQ1Nr 7S
We are providing you with an Owner-Builder Acknowledgment and 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 offlcial address Indicated. An 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.)
1. 1 understand,a frequent practice of unlicensed persons 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 subject to serious financial risk for any injuries sustained by
an unlicensed person and hislor her employees while working on my property. My homeowner's insurance may not
provide coverage for those injuries. I am 611fullyacting as an Owner-Builder and am aware of the limits of my
insurance coverage for injurieIs to workers on my property.
/
J %2. 1 understand building permits are not required to be signed by property owners unless they are responsible for
theconstruction and are not hiring a licensed Contractor to assume this responsibility.
164 h 3. 1 understand as an"OI ner-Builder" I am the responsible 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.
A4. I understand Contractors are required by law to be licensed and bonded in California and to list their license
numbers on permits and contracts..
Z5. 1 understand if I empl ly or otherwise engage any persons, other than California licensed Contractors, and the
total value of my construction Is at least five hundred dollars($500), including labor and materials, I may be
considered an"employer" under state and,federal law.
A6. I understand if I am co nsidered an"employer" under state and federal law, I must register with the state and
federal government, withhold payroll;taxes, provide workers'compensation disability insurance, and contribute to
unemployment compensationifor each "employee." I also understand my failure to abide by these laws may subject
me to serious financial risk.
47. 1 understand under California'Contractors'State License 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.
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 orImatenals.
OlrnerBuilderForm_2010.doc revised 04/14//0
L
19. 1 understand I may;obtain;more information regarding my obligations as an "employer"from the Internal
Revenue Service, the United Sfates Small Business Administration, the California Department of Benefit Payments,
and the California Division of Industrial Accidents. I`also understand I may contact the California Contractors' State
License Board(CSLB)at 1-800=321-CSLB (2752)or www.cslb.ca.gov for more information about licensed
contractors.
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 construction activity at the site address listed above.
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-Builders as well as employers.
�12. 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 to understand that if an unlicensed Contractor or
employee of that individual or firm.is injured while working on 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 lending agency information.)
I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued
(Sec 3097 Civ.)
Lender Name: Lender Address:
Before a building permit can be Issued,this form must be completed and signed by the property owner and
returned to the agency responsible forissuing the permit. Note:A copy of the property owner's driver's license,
form notarization, or other verification acceptable to the cimaybe required to be presented when the permit is issued
to verify the property owner's.si nature.
Property Owner's Signature: Date: r^--4 -� b I 10(2-
--------------- ----- - -- - - - -=------------------------------------------------------------------------------------------------
(NOTE: The--follow--in---Au-th--o-rt-zatio--- -n,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 for the Owner-Builder).
AUTHORIZATION OFAGENT TOACT 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.
Scope of Construction Project(or Description of Work):
Project Location or Address:
Name of Authorized Agent: Tel No
Address of Authorized Agent:
I declare under penalty of perjury that I am the property owner for 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 presented when the permit is issued to verify the property owner's
signature.
Property Owner's Signature: Date:
Oi+vmrBuilderForm 1010.doe revised 04114110
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255
(408) 777-3228• FAX(408)777-3333 • buildinG(a),cuoertino.cra I�O � '
CUPERTINO
[:]NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION/TI ❑ REVISION/DEFERRED ORIGINAL PERNE?X
PROJECTADORFSS yl 5TOKE5 AVE/ NPERTINQ AF N# c;2- Le L' —1 03 C)
OWNER NAMEI�6�Ri}W f}"L PxONE1j0q 921 'V71Z E�MAn- D•AGIRAW/}L AG/'7 Fl/tM
STRlzTT ADDRESS CITY. STATE.ZIP
CONTACT NAME PHONE E NAI.
STREETADDRESS CITY,STATE ZIP FA.Y
❑OwNER OWNER-BUILDER ❑ OWNERAGENT ❑ CONTRACTOR ❑CONTRACri RAGENT ❑ AItctmr:R ❑evcni ER ❑ DEV='OPER ❑ Tn.'ANr
CONTRACTOR NAME LICENSE NUMBER LICENSE TYPE BUS.LIC%
COMPANYNA.ME E-MAIL FAX .
STREET ADDRESS CITY.STATE,ZIP PHONE
ARCIHT ECr/ENOMEER NA-NE LICENSE NUMBER BUS-LTC%
COMPANY NAND: E-MAIL FAX
STREET ADDRESS CIT'.STATE,ZIP PHONE
DESCRPPTTON OF WORK CN AN CtG WN TV6 TO WHIRLP001— i CHANGE SINK TO _V0U61_&
i SINK TTLF_S AICD C0151NF_ TS
E)CSTGNG USE PROPOSED USE CONSTIL TYPE %STORIES
USE TYPE OCC SQ.FT. VALUATION(S)
FXLSTG NEW FLOOR DEMO TOTAL
AREA AREA AREA NET.VIEA
BATHROOM /'y KTTCIQ•]N 011¢R
REMODELAREA x v REMODEL AREA REMODELAREA
PORCH ARTA (DECK AREA TOTAL OECK/PORCH AREA GARAGE AREA: DETACH
ATTACH
4 DWELLGNG UNMS 0 A SECOND UNIT YES SECOND STORY ❑YES
BEDSGADOEDt ONO ADDITION? ONO
PRE-APPUCAT'.ON ❑YES IF YES PROVIDE COPY OF IS TBE BLDG AN
❑YES RECEIVED BY: - TOT VALUATION:
PLANNING APPL% ONO PLANNING APPROVAL LETTER EICBLER HOME' ❑NO
By my signature below,I certify to each of the following I am the property owner or authorized agent to act on the prirperty owner's behalf. I have read this
application and the information I have provided 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 building citestruction. laulbortzerepra=Moves of Cupertino to enter the above-identilled property for inspection purposes.
siguattue ofApplicam/Agenk Date: - (yw,.QSUPPLEMENTAL INFORMATION REQUIRED PLANCHECK TYPE ROUTING SLIP
New SFD or Multifamily dwellings: Apply for demolition permit for ❑ OVER-THE-COUNTER ❑ BUILDING PLAN gEvtp}y
existing building(s). Demolition permit is required prior to issuance of building
permit for new building. ❑ EXPRESS ❑ PUNNING PLAN REVIEW
_Commercial Bldgs: Provide a completed Hazardous Materials Disclosure C1 STANDARD ❑ PUBLIC WORKS
To 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
❑ bWOR ❑ SA•NITARY SEWER DISTRICT
Submittal of Building Permit application.
❑ eNvmoNwtNT.wgP,Ire
B1dgApp_2011.doc revised 06121/11