B-2016-2071 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2016-2071
21331 COLUMBUS AVE CUPERTINO,CA 95014-4921(362 04 00 Z) OWNER-BUILDER
OWNER'S NAME: BHASKAR SREEKANTH AND SREEKANT I BANUMATHY DATE ISSUED:06/06/2016
OWNER'S PHONE:650-279-3750 PHONE NO:
LICENSEDCONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class Lic.#
Contractor OWNER-BUILDER Date X BLDG _ELECT _PLUMB
MECH X RESIDENTIAL_COMMERCIAL
I hereby affirm that I am licensed under the provisions of Chapte�9(commencing
with Section 7000)of Division 3 of the Business&Professions Code and that my
license is in full force and effect. JOB DESCRIPTION:
ADD DECK(29'X 6)FREE STANDING;FLUSH TO THE NANA
I hereby affirm under penalty of perjury one of the following two declarations: WALL;ADD ATTIC SPACE TO GARAGE
1. I have and will maintain a certificate of consent to self-insire 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.
2. 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. Sq.Ft Floor Area: Valuation:$7000.00
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above APN
information is correct.I agree to comply with all city and countyl ordinances Number: Occupancy Type:
362
and state laws relating to building construction,and hereby authorize 362 04 002
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 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 regulations per the Cupertino Municipal Code,Section 9.18. 180 DAYS FROM LAS , E SPECTION.
Signature Date 6/20 6 Issued by:Alex Vallelunea016
Date:06/06/2
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Ifaw for one of the RE-ROOFS:
following two reasons: All roofs shall be inspected prior to any roofmg material being installed.If a roof is
1. I,as owner of the property,or my employees with wages as 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 int ended or offered for
inspection.
sale(Sec.7044,Business&Professions Code)
I,as owner of the property,am exclusively contracting wi licensed Signature ofApplicant:
contractors to construct the project(Sec.7044,Business&professions Code). Date:6/6/2016
I hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
r. I have and will maintain a Certificate of Consent to self-insure for Worker's
Compensation,as provided for by Section 3700 of the Labpr 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 Insurance,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 I 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
/a. I certify that in the performance of the work for which this emn is issued,I Health&Safety Code,Section 25532(a)should I store or handle hazardous
material. Additionally,should I use equipment or devices which emit hazardous
shall not employ any person in any manner so as to become subject to the air contaminants as defined by the Bay Area Air Quality Management District I
Worker's Compensation laws of California. If,after making this certificate of will maintain compliance with the Cupertino icipal Code,Chapter 9.12 and
exemption,I become subject to the Worker's Compensatioi i provisions of the the Health&Safety Code,Section 551,1,25533,and 255A4.
Labor Code,I must forthwith comply with such provisions or this permit shall
be deemed revoked. Owner or authorized agent: 20
APPLICANT CERTIFICATION Date:6/6/2016
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 agai st liabilities,
judgments,costs,and expenses which may accrue against saidCity 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 Cu ertino Municipal ARCHITECT'S DECLARATION
Code,Section 9.18. I understand my plans shall be used as public records.
Licensed
Signature 62 1 1 Date professional
CONSTRUCTION PERMIT APPLICATION
K COMMUNITY DEVELOIMENT DEPARTMENT- BUILDING DIVISION
10300 T ORRE AVENUE• CUPERTINO, CA 95014-3255 B .
(408) 777-3228 • FAX(.08)777-3333 . building(a)cupert!no,org
CUPERTINO 6-2-01
❑ ?`t-W CONSTRUC TION 0 ADDITION ❑ ALTER4TIOh/TI REVISION/DEFERRED ORIG�?AL PER7/iIT
PROJECT ADDRESS
2-I S 3 C Cot-0 M-607S� AVE I APN R � w'j(iI 0c), —
OVNER?\AMM `'J- £l�y��I 15 �� I PHO?t RJ /�`,�/ �—�✓ E-h'4IL��ic�G+`�f�1V t 'fl Pg
STREET.4DDRFSS /C,O> ,7 1V I h ,.0 CITY, STATE,ZIP ^ n — I FAX
CONTACT NAME PHONE �/E-124IL
ADDRESS STREET.a. -� CITY,STATE, ZIP FAX
❑ 0-A INER ❑ OP'NTR-BUMDER ❑ O;;1,7RAGENT ❑ (CONTRACTOR ❑CONTRACTORAGENT ❑ ARCHITECT ❑ENGL\tER ❑ DEVELOPER ❑ TENA11°T
CON �TOR KA IF� LIC-NSE TYPE � BUS.LIC:
FAX
51-I2F-�cT/uDDRESS y CITY,STATE ZI;? , �^O/n (�a�
ARCHITECT/ENG /1iw ���LIC NSE NMBER 6BUS.LIC e
COMPANY NAI115E E-MIAIL ` s+K FAX �
STREET ADDRESS CITY,STATE,ZIP I PHONE
DESCRIPTIOT:OF\d'OP1i
4-777
EXISTING USE PROPOSED USE CONST. TYPE STORIES
USE TYPE OCC. SQ.FT. V?..LUATION(S)
EXlSTG NEW FLOOR DEMO TOTAL
.AREA AREA AREA NET AREA
BATHROOM KITCHEN I OTHER
REIi,ODELAREA REMODEL AREA REMODELAREA
PORCH.RHA DECK.12,EA TOTAL DECKTORCH AREA :.R AGE.^.REP.: Lj DETACH
❑ATTACH
DWELLING UNITS: IS A SECOND UNIT ❑YES SECOSD STORS' ❑YES
EELNGADDED? ❑NO .4D�ITIIN.. ❑]t•0 I //
i
PR :=-P?LiCAT10' ❑YES IF)=-S,PRO\'IDE COPY OF IS THE BLDG.t\ ❑ T i L'A71C�:
PLAN'TINGAPPL# ❑NO PLANNING APPROVALLE17ER EI�TURHO?ATE? ONO
-�
By my signzfire below,I Certify to each 0f the fib �g: I am the propel owner or authorized agent to act on the�prope ty o+ner's behal . I have read-,'Ms
application and the informatioonhan,e provide is COT.cc I ha}'e read the Description of Work and verify it is accurate. I amee to comply vrith all applicable local
ordinances and state law re.lbuildin-cOnstru ,0n. I authorize r= 'es : fives of Cupertino to enter the aboy+-i entifl property,for inspection purposes.
SignatureofApplicant/ABenDate:
SLTPLE\1j i IFOR7\ ATiON RE'QUIRED t
s y PL4\CHECI.TIPE ;i3 ��T saa Is y RQI TI\G�LIPP .
New SFD or Aiultifamily dwellings: AD 13,for demolition pennit for YAVE,
`�ti FR TSE COL\TFRUILDI\G PLS\RE1 IE\6
existing building(s). Demolition pel it is required prior to issuance of building Jn f h, ti
yrs ,.�mn zi x< P�� rc '�''`?tit, �!\i,�•y-},��i
Pen-nit.or new l)Uilding. F\�RESS a 3 rt ❑ Pr s\\L\G Pr i REQ IE`I
, _.3Pl'.�' ixz' v^"S^*cb 4B f1=-:+w ..
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Con nlerci2l Bldgs: Provide a completed Hazai-dous';4aterials Disclosure ST \D4RD T ❑i PLELIC\�ORIut y z i
forin if am Hazardous 1i6aterials are bean-used as Dart OI -,his Pic ect.
��L31'GE ��id .� -� `p",�^ ❑�FIREDEPT����"-z`� s '.'1
_ Cop} of P12L]ll�a approval Letter or-�--etinv ;]t1 PI2nniPa DrIOr i0
z 3 cx r �'
subi-nittal of Building Permit application. s�4JOR ^,,ti ❑ S \IT:R]SE`'�ER DISTRICT'
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�<E\�IRO\.4iENT.4I HEALTH.s b
!,- Bldg pp_2011.docrevised06/21/11
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` ®INNER-BUILDER DISCLOSURE FORM
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255
(408)777-3228•FAX(408)777-3333•build ing(a)cupertino.org
CUPERTINO
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 1,323
( C�/ n AV APN p _ _ �B,� FBP# �71M to
f� I
OWNER NAME�RCEK; T O NER ADDRESS (��3 3' C O L0 M
DESCRIPTION DOFFWORK: I 5
ft C Q
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 official 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.)
. I understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner-
uS Silder
"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 his or her emplo�ees while working on my property. My homeowner's insurance may not
provide coverage for those injuries. I am willfully acting as an Owner-Builder and am aware of the limits of my
insurance coverage for injuries to workers on my property.
`tom ..I understand building permits are not required to be signed by property owners unless they are responsible for
construction and are not hiring a license
d Contractor to assume this responsibility.
4precunderstand as an "Owner-Builder"I I am the responsible party of record on the permit. I understand that I may
t
myself from potential financial riskby hiring a licensed Contractor and having the permit filed in his or her
name instead of my own.
understand Contractors are requir d by law to be licensed and bonded in California and to list their license
n tubers on permits and contracts.
5. 1 understand if I employ or otherwis engage any persons, other than California licensed Contractors, and the
t slue of m construction is at least five hundred dollars $500 , including labor and materials, I may be
Y ( ) 9 Y
considered an"employer"under state and federal law.
6. 1 understand if I am considered an "employer" under state and federal law, I must register with the state and
eera government,withhold payroll taxes, provide workers'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.
-7,f 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.
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.
OwneJBuilde1Forin 2010.doc revised 04/14/10
i
ZY'9. I understand I may obtain more information regarding my obligations as an "employer"from the Internal
Revenue Service,the United States 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.csib.ca.gov for more information about licensed
contractors.
_,Yl 0. 1 am aware of and consent to anOwner-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.
1h11. I 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.
I agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the
icensed contractors are regulated b laws designed to protect the public. If
information I have provided on this form. g y g P
p
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 ar d 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 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 si natur .
Property Owner's Signature. Date:
---------------------------------------------------------------------------------------------------------------------------------------------
(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 for the Owner-Builder).
AUTHORIZATION OF AENT 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.
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 �roperty 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 requied to be presented when the permit is issued to verify the property owner's
signature.
Property Owner's Signature: Date:
J
OHnzeiBuildeiForm 2010.doc revised 04114/10
Building Department
City Of Cupertino
10300 Torre Avenue
Cttpertino,CA 95014-3255
C U P E RT 1 N O Telephone:408-777-3228
-
Fax:408-777-3333
CONTRACTOR/SUBCONTRACTOR LIST
JOB ADDRESS:
PERMIT# ZD
OWNER'S NAME: GAEE
PHONE#
GENERAL CONTRACTOR: ` BUSINESS LICENSE# `
ADDRESS:
of' Q q I CITV/ZIPCODE:
*Our municipal code requires all businesses working in the city to have a City of Cupertino business license.
NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTIONS) WILL BE SCHEDULED UNTIL THE
GENERAL CONTRACTOR AND ALL SUBCONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO
BUSINESS LICENSE.
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following information:
SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE#
Cabinets &&Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring/Carpeting
Linoleum/Wood
Glass/Glazing
Heating
Insulation
Landscaping
Lathing 4
Masonry
Painting/Wallpaper -
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
:01.411
J
®, 1
Owner/Contractor Signature Date