B-2016-1930CITY OF
CUPERTINO BUILDING PERMIT
BUILDING ADDRESS:
CONTRACTOR:
PERMIT NO: B-2016-1930
21891 LOMITAAVE CUPERTINO, CA 95014-2829 (357 16 075)
ALI'S CONSTRUCTION
& REMODELING INC
SAN JOSE, CA 95129
OWNER'S NAME: KUILA KAUSHIK AND MONDAL DIPANW
TA
DATE ISSUED: 05/11/2016
OWNER'S PHONE: 510-304-2370
PHONE NO: (408) 441-0967
LICENSED CONTRACTOR'S DECLARATION
BUILDING PERMIT INFO:
License Class GENERAL BUILDING CONTRACTOR Lic. #90 433
Contractor ALT'S CONSTRUCTION & REMODELING INC Date�,01/31/2018
X BLDG X ELECT _PLUMB
I hereby affirm that I am licensed under the provisions of Chapter9 (commencing
MECH X RESIDENTIAL _ COMMERCIAL
with Section 7000) of Division 3 of the Business & Professions Code and that my
license is in full force and effect.
JOB DESCRIPTION:
INSTALL TEMPORARY POWER (GROUNDED TO PORTABLE WC)
I hereby affirm under penalty of perjury one of the following two declarations:
(V O *A M P
t. 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
p2 performance of the work for which this permit is issued.
'2. I have and will maintain Worker's Compensation Insuranc as for by
, provided
Section 3700 of the Labor Code, for the performance of the work for which this
Sq. Ft Floor Area:
Valuation: $500.00
permit is issued.
APPLICANT CERTTFICAT16N
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
APN Number:
Occupancy Type:
and state laws relating to building construction, and hereby authorize
357 16 075
representatives of this city to enter upon the above mentionedproperty for
inspection purposes. (We) agree to save indemnify and keep harmless the
City of Cupertino against liabilities, judgments, costs, and expenses which
PERMIT EXPIRES IF WORK IS NOT STARTED
may accrue against said City in consequence of the granting of this permit.
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
Additionally, the applicant understands and will comply with all non -point
source regulationsthe Cupertino Municipal Code, Section 9.18.
180 DAYS FROM LAST CALLEDANSAWTION.
mer
Signature Date 05/ 1/2016
Issued by:
Date: 05/11/2016
OWNER-RUTLDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License I aw for one of the
RE -ROOFS:
following two reasons:
All roofs shall be inspected prior to any roofing material being installed. If a roof is
t. 1, as owner of the property, or my employees with wages a their sole
installed without first obtaining an inspection, I agree to remove all new materials for
compensation, will do the work, and the structure is not m ended or offered for
inspection.
sale (Sec.7044, Business & Professions Code)
z. I, as owner ofthe property, am exclusively contracting with licensed
Signature of Applicant:
contractors to construct the project (Sec.7044, Business & Professions Code).
Date: 05/11/2016
I hereby affirm under penalty of perjury one of the following three declarations:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
r. 1 have and will maintain a Certificate of Consent to self -in ure for Worker's
Compensation, as provided for by Section 3700 of the Lab r Code, for the
performance of the work for which this permit is issued.
HAZARDOUS MATERIALS DISCLOSURE
2. I have and will maintain Worker's Compensation Insuranc , as provided for by
I have read the hazardous materials requirements under Chapter 6.95 of the
Section 3700 of the Labor Code, for the performance of th work for which this
California Health & Safety Code, Sections 25505, 25533, and 25534. I will
permit is issued.
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
3. I certify that in the performance of the work for which this permit is issued, I
Health & Safety Code, Section 25532(a) should I store or handle hazardous
shall not employ any person in any manner so as to become subject to the
material. Additionally, should I use equipment or devices which emit hazardous
air contaminants as defined by the Bay Area Air Quality Management District I
Worker's Compensation laws of California. If, after makir g this certificate of
will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and
exemption, I become subject to the Worker's Compensatio provisions of the
the Health & Safety Code, Sec 'on 5505, 25533, and 25534.
Labor Code, I must forthwith comply with such provisions or this permit shall
be deemed revoked.
Owner or authorized agent: 711Q
APPLICANT CERTIFICATION
Date: 05/11/2016
I certify that I have read this application and state that the above information is
CONSTRUCTION LENDING AGENCY
correct. I agree to comply with all city and county ordinances and state laws
I hereby affirm that there is a construction lending agency for the performance
relating to building construction, and hereby authorize representatives of this city
of work's for which this permit is issued (Sec. 3097, Civ C.)
to enter upon the above mentioned property for inspection purposes. (We) agree
Lender's Name
to save indemnify and keep harmless the City of Cupertino against liabilities,
judgments, costs, and expenses which may accrue against said City in
Lender's Address
consequence of the granting of this permit. Additionally, the applicant understands
and will comply with all non -point source regulations per the Cupertino Municipal
ARCHITECT'S DECLARATION
Code, Section 9.18.
1 understand my plans shall be used as public records.
Licensed
Signature Date 05/1/2016
Professional
GENERAL PER ,IT APPLICATION MEP
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • C UPERTINO, CA 95014-3255 misc
CUPERTINO (408) 777-3228 • FAX (408)I777-3333 • building0kupertino.org
❑ PLUMBING ❑ MECHANIC [:]ELECTRICAL ❑ MISCELLANEOUS
PROJECT ADDRESS �7 + I ��m' /+I A v� li APN # 2 � / / _ _ O 1 ��
OWNER NAMEG�� ` u j �I', PHONE i�10 3p1� .231-,6 E-MAIL
STREET ADDRESS �+� CITY, STATE, ZIP FAX
CONTACT NAME /] / l PHONE 40 fd %q (� E-MAIL
STREET ADDRESS j D 1 l 5 gL q n W I(3 I V 0 CITY, STATE, ZIP C L� IkJ �/.� � MT OI / � FAX
{i
❑ OWNER ❑ OWNER -BUILDER ❑ OWNERAGENT CONTRACTOR ❑ CONTRACTORAGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME /� �(C co
,n 51.,rCk rL( io� LICENSE NUMBER q O 7 11 3 LICENSE TYPE rS BUS. LIC # � 2
COMPANY NAME /Ij'CIt Z) J l S�I'Y1Li rll %vel E-MAIL %� G S -
! Ci(M_' J YWj*'h RJ YQYIc! FAX l
STREET ADDRESS ll(gl ( I�A A ecA ,� di CITY, STATE, ZIP 5 / PHONE 140 p - c- ! ! h /96
ARCHITEGT/ENGINEER NAME LICENSE NUMBER BUS. LIC #
COMPANY NAME
E-MAIL
STREET ADDRESS CITY, STATE, ZIP
FAX
PHONE
TOTAL VALUATION:Q • REC`
By my signature below, I certify to each of the following: I am the property owner or autho ' gent -t wner's behalf. I have read this
application and the infonnation I have pro ' ed 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 bui '` c nstraction. I authorize representatives of Cupertino to enter the above -identified property for inspection purposes.
Signature of Applicant/Agent: ' % ' i' Date: / G I ` V
SUPPLEMENTAL INFORMATION REQUIRED
MEPMiscApp_2011.doe revised 06/21/11
USE OF ❑ SFD .,DUPLEX ❑ MULTI -FAMILY
BUILDING: ❑ COMMERCIAL
PROJECT IN, WI DDLAND ❑ YES
URBAN INTERFACE AREA ❑ NO
PROJECT IN
` FLOOD ZONE
❑ YES
❑ NO
IS THE BLDG AN ❑ YES
EICHLER HOME? ❑ NO
DESCRIPTION OF WORK
7 ems r
, 0 &�- "r
TOTAL VALUATION:Q • REC`
By my signature below, I certify to each of the following: I am the property owner or autho ' gent -t wner's behalf. I have read this
application and the infonnation I have pro ' ed 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 bui '` c nstraction. I authorize representatives of Cupertino to enter the above -identified property for inspection purposes.
Signature of Applicant/Agent: ' % ' i' Date: / G I ` V
SUPPLEMENTAL INFORMATION REQUIRED
MEPMiscApp_2011.doe revised 06/21/11