12060174 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 19369 GREENWOOD CIR CONTRACTOR:BROTHERS HOME PERMIT NO: 12060174
IMPROVEMENT
OWNER'S NAME: BIIUTA VIPUL AND HETAL 2510 DOUGLAS BLVD DATE ISSUED:06292012
OWNER'S PHONE: 4088826412 ROSEVILLE,CA 95661 PHONE NO:(408)295-0680
❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT r PLUMB r
License Class C` Lick — L - r r r
l MECH RESIDENTIAL COMMERCIAL
Contractor Date
1 hereby affirm that l am licensed under the provisions of Chapter 9 30B DESCRIPTION: REMOVE AND REPLACE(10)WINDOWS AND(2)DOORS.
(commencing with Section 7000)of Division 3 of the Business'&Professions BEDROOM WINDOWS SHALL MEET EMERG17NCY EGRESS
Code and that my license is in full force and effect. REQUIREMENTS OF THE 2010 CRC
I 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.
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 Sq.Ft Floor Area: Valuation:$7595
permit is issued. '
APPLICANT CERTIFICATION APN Number:37543012.00 Occupancy Type:
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 PERMIT EXPIRES IF WORK IS NOT STARTED
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may ac c against aid City in consequence of the WITHIN 180 DAYS OF PERMIT ISSUANCE OR
granting of this permit. Ad y,the icanl understands and will comply 180 DAYS FROM LAST CALLED INSPECTION.
with all non-point sour ulalions the Cupertino Municipal Code,Section
9.18.
Issued by: E+�1✓ ATG Date:
Signature Date-=� Z�
❑ OWNER-BUILDER DECLARATION
RE-ROOFS:
hereby affirm that 1 am exempt from the Contractor's License Law for one of All roots shall be inspected prior to any roofing material being installed.If a roof is
the following two reasons: installed without first obtaining an inspection,I agree to remove all new materials for
I,as owner of the property,or my employees with wages as their sole compensation, inspection.
will do the work.and the structure is not intended or offered for sale(Sec.7044,
Business&Professions Code) Signature of Applicant: Date:
I,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:
I have and will maintain a Certificate ofConsenl to self-insure for Worker's HAZARDOUS MATERIALS DISCLOSURE
Compensation,as provided for by Section 3700 of the Labor Code,for the 1 have read the hazardous materials requirements under Chapter 6.95 of the
performance of the work for which this permit is issued. California health&Safety Cade,Sections 25505,25533,and 25534. 1 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 I store or handle hazardous material.
Additionally,should I use equipment or devices which emit hazardous air
permit is issued. contaminants as defined by the Bay Area Air Quality Management District I will
I certify that in the performance of the work for which this permit is issued,I shall maintain compliance with the Cupertino 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 Code,Secti 5505,25533,and 25534.
Compensation laws of Cafforia. If,after making this certificate of exemption,I
become subject to the Worker's Compensation provisions of the Labor Code,I must Owner e
forthwith comply with such provisions or this permit shall be deemed revoked. ate:
CONSTRUCTION LENDING AGENCY
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is I hereby 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 stale 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
costs,and expenses which may accrue against said City in consequence of the
granting of this permit.Additionally,the applicant understands and will comply ,ARCHITECT'S DECLARATION
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18. 1 understand my plans shall be used as public records.
Signature Date Licensed Professional
i� (v0� 7y
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION '
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255
CUPERTINO (408)777-3228• FAX(408)777-3333• buildine(G)cuoertino.orG
❑NEW CONSTRUCTION ❑ ADDCITON ALTERATION/TI ❑ REVISION/DEFFRIUD ORIGINAL PERMIT#
PROIECT.4DORSS `I o / �� APN# 0
ME
OWNER NA (f/ PHONE _ �Yl
ST=ADDRESS J /_� Qr CITY. STATE.IIP T.a t / +- SUI FAX .
CONTACT NAME (, �I P�O(� w 1 E-NAEL
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S73LEETADDRESS' RTY'ST'TE, ZIP L FAX
SCPA
❑owNER ❑ OWNER BURDER ❑ Ow,M AGENT CONTRA=R ❑CONTRACTORAGENT ❑ ARCHr ECr ❑�GDIEA ❑ DEVELOPER ❑TENANT
CO ORNC
o�1 AME L ER 'CENSE TYPE BUS.LICA
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COMPANY N E-MAIL FAX
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ARCHrrECT/ENGINEFR NE LICENSE NUMBER 7J ! BUS.LIC4 1p
COWANY NAME E-MAIL FAX
STREET ADDRESS QTY,STATE,LIP PHONE
DESCRIPTION OF WORK
W Mto Owe> b We Ar LcKe of w - 64 taskil
IDC 4T D wV//)5oL USE PRO USE CON ' aSTap TC
USE TYPE CCC. SQFr. VA OAIION S7
=TG NEW FLOOR OEMO TOTAL
AREA AREA AREA NETAREA
BATHROOM KRCFD:N OTHER
REMODELAREA REMODELAREA REMODELARPA
PORP AREA DECKAREA TOTALDECIOPORCHAREAGARAGE MEA OETACH
ATTACH
4 Dw ' G UNITS: IBA SECOND UNTT 0M SECOND STORY YES
BMGADD®r []NOADDIITONr ❑NO
PRE-APPLICATION ❑YES rF YES.PROVIDE COPY OF 1S THE BLDG AN ❑YEs RECEIVED TOTAL VAIUAT:ON:
PLANN[NGAP []NOIN
PL4 NO PLANNING APPROVAL LETTERsucaLaRHOME' []NO77SS Id W
By my signature below,I certify to each of the fpllowiD the property awn authorized agent m act on dte pmVmty owner's behalf. I have read chis
application and the information I have provided is co 'have rvrd rhe Des tion of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating to building co cdon. I authorize mtives of Cupertino to enter the above/-id dyed/ptoperry for inspection purposes.
Sign-r of AppEcznt/Agerm Due:
SUPPLEMENTAL INFORMATION REQ PLAN CRYCK TYPE R0U`MG SLIP
New SFD or Multifamily dwellings: Apply for demolition permit forI�f OVER-TBE-COUNTER J BImmmc Pur REvmw
existing building(s). Demolition permit is required prior to issuance of building J--N
permit for new building. ❑ E Bess ❑ PLANMG Pr.AN R W
Commercial Bldgs: Provide a completed Hazardous Materials Disclosure Cl STANDARD ❑ PUBucwORxS
form if any Hazardous Materials are being used as part of this project.
Cl raBGE ❑ ETRE OFF'
_Copy of Planning Approval Letter or Meeting with Planning pnor to
submittal of Building Permit application. ❑ MA.ron ❑ SANITARY SEWFA DISTRICT
❑ EWMON-AENTAL HFALTH
B!do fpp_2011.doc revised 06121111
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04 COMMUNITY DEVELOPMENT DEPARTMENT JUN 29 2012
BUILDING DIVISION-CUPERTiNO
APPROVED BY'
This set of plans and specifications MUST be kept at the
job site during construction. It is unlawful to make any
changes or alterations on same,or to deviate
therefrom, without approval from the Building Official.
v The stamping of this plan and specifications SHALL NOT
be hold to permit or to be an approval of the violaEon y�
of any provisions of any City/Ordinance or State Law.
BY
9 /a--
DATE �� t
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