D-2016-0393CITY OF CUPERTINO
BUILDING PERMIT
BUILDING ADDRESS:
CONTRACTOR:
PERMIT NO: D-2016-0393
20790 GREENLEAF DR CUPERTINO, CA 95014-1819 (326 30 175)
OWNER -BUILDER
OWNER'S NAME: SAMANTAARINDAM AND SANJUKTA
DATE ISSUED: 07/12/2016
OWNER'S PHONE: 310-936-1868
PHONE NO:
LICENSED CONTRACTOR'S DECLARATION
BUILDING PERMIT INFO:
License Class Lic. #
Contractor OWNER -BUILDER Date
—BLDG —ELECT —PLUMB
MECH X RESIDENTIAL _ COMMERCIAL
I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing
with Section 7000) of Division 3 of the Business & Professions Code Ind that my
license is in full force and effect.
JOB DESCRIPTION:
DEMO SFD (1008 S.F.)
I hereby affirm under penalty of perjury one of the following two declarations:
1. 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.
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 vt%ork for which this
Sq. Ft Floor Area:
Valuation: $12000.00
permit is issued.
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above
APN Number:
Occupancy Type:
information is correct. I agree to comply with all city and county ordinances
326 30 175
R-3 (Custom)
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 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 LAST C INSPECTION.
Signature Date 07/12/2016
Issued by: MELISSA NAMES"';
Date: 07/12/2016
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of the
RE -ROOFS:
All roofs shall be inspected prior to any roofing material being installed. If a roof is
following two reasons:
t. I, as owner of the property, or my employees with wages as eir 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 intended or offered for
inspection.
sale (Sec.7044, Business & Professions Code)
I, as owner of the property, am exclusively contracting with �icensed
Signature of Applicant:
i' contractors to construct the project (See.7044, Business & Professions Code).
Date: 07/12/2016
I hereby affirm under penalty of perjury one of the following three declarations:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
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
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 of the work for which this
California Health & Safety Code, Sections 25505, 25533, and 25534. I will.
performance
permit is issued.
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
s. 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
Health & Safety Code, Section 25532(a) should I store or handle hazardous
material. Additionally, should I use equipment or devices which emit hazardous
defined by the Bay Area Air Quality Management District I
Worker's Compensation laws of California. If, after making this certificate of
air contaminants as
will maintain compliance with the Cupertino Municipal Co Chapter .2 and'
exemption, I become subject to the Worker's Compensation provisions of the
Labor Code, I must forthwith comply with such provisions or this permit shall
the Health & Safety Code, Sections 5505, 25533, and 255-34..,!)3 i
be deemed revoked.
Owner or authorized agent:
APPLICANT CERTIFICATION
Date: 07/12/2016
I certify that I have read this application and state that the above information is
CONSTRUC ON LENDING AGENCY
I hereby affirm that there is a construction lending"agency for the performance
correct. I agree to comply with all city and county ordinances and state laws
of work's for which this permit is issued (Sec. 3097, Civ C.)
relating to building construction, and hereby authorize representatives of this city
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 agaist liabilities,
judgments, costs, and expenses which may accrue against saidCity in
Lender's Address
consequence of the granting of this permit. Additionally, the ap licant understands
ARCHITECT'S DECLARATION
and will comply with all non -point source regulation p r the Cupertino Municipal
71
I understand my plans shall be used as public records.
Code, Section 9.18. /
ci�� ✓ l
Signature 7/016
Licensed
professional
V
CUPERTINO
DEMOLITION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228 • FAX (408) 777-3333 • building(a)cupertino.M zo
16-a 3 93
PROJECT ADDRESS` I
75–
,`� A"' 3?-4-30--175–
?-4-3O--/
OWNER NAME
OWNERNAME ii� G �J>iY►� �J> I
' LL
PHONE r� jO — L13 % / l,� j 8 E-MAIL
/ 1 b a (3
STREET ADDRESS l
CITY, STATE,, ZIP F,9X
CONTACT NAME I
PH02\B� ,- fj .
E-MAIL
�
STREETADDRESS
CITY, STAT ZIP ti
FAX
❑ Ov q TEP, ORrNER-BUILDER ❑ Q%,`NER AGENT ❑ CI
NFRACTOR ❑ CONTRACTOR AGE!\rr ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME I
LICENSE NUMBER LICENSE TYPE
BUS. LIC n.
COMPANY NA %4E
I
E-MAIL
FAX
STREET ADDRESS
I
CITY, STATE, ZIP
PHONE
DESCRIPTION OF WORK. Q - I
VV Q i
too
RESIDENTIAL
#'DNiTLLING
I
vj ttx 4 rF 1 * $AFFICEI7SE0I�LYt sxS 't 'ty r`'
FLOOR AREA
UNITS
y s USE•�..k f 0CG. 4= ..TYPE Y-+�
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VALUATION. •. +
COIvLNIERCTAL
Ng `E ry 4 .rtn �{FyM
FLOOR AREA
TYPE OF CONSTRUCTION
R STORIES
I
=u4 ' r ! jl
ag
AQMD JOB NUMBER
TOTAL VALUATION:
J
c)
By my signature below, I certify to each of the following: I atn
the property owner or a n e owner's behalf. Lhave r ad this
application and the information I have provided is correct. I have
lead the Description of Work and ve ' it i Late. I agree to comply with all applicable local
ordinances and state laws relating to building construction. I authorize
re re entatives of Cupertino t er the above -identified property for inspection purposes.
f
Signature of Applicant/Agent: Date:
STJPPLEMENTAL INFORMATION REQ PRIOR TO ISSUANCE OF DEMOLITION PERMIT
t OFFICE USE ONLY X
Provide Job Number from Bay Area Air Quality Management District 1v anv.baaamd.or- @ 415-749-4762.
LOT CHECK,T PE
_
5 r
Provide three copies -(Residential) or six copies (Co merical) of a site plan showing protection for any trees 10
0 tisxPr.Ess
in diameter or more at 3' above grade.
❑ L sTAi.DARnl s
t �
❑
Provide letter from PG&E (408-72573325) stating all g s and electric has been disconnected.
LARGE
— Provide a letter of inspection, tests, and abatement of arty Hazardous Materials. Letter to be initiated by person(s)
111AJ0R
ce tified in asbestos, mercury and/or hazardous material examination.
Planning Dept clearance to verify building is not considered an historical landmark. Allow 10 business days.
`
—
Provide letter of clearance of all vermin from a licensed pest control contractor.
—
artment at 40 I -777-3104 and schedule a "habitable dwelling" inspection
Applicant shall cq the Public Wor �s Dg (o
WCinVt � —7IL(l
>'
_ Provide signed Debris Bin and Relyclable Materials form.
0, JJA
S�� fog
Demo.4pp_2013.doc remised 02/13/13
-
CUPERTINO
OWNER-BUILDEIR DISCLOSURE FORM
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408)777-3228 • FAX (408) 777-3333 • buildinQCa)cupertino.orn
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 AD B /_ - _ I A _ Qi TD.- I APS i 31 A a i r%. ] IBP# I
WN,N�ME t' Lam. II OWNER ADo DRESS
O.T0, " ..z, l) /, f -c-,7,. 4,.Lo lam. -no -w -4i 11U
OF
We are providing you with an Owner -Builder A8knowledgment 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.
Please read and initial each statement below to signify you understand or verify this information.)
�-S 1. 1 understand a frequent practice of r nlicensed 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 his or her employees while working on my property. My homeowner's insurance may not
provide coverage for those injuries. I am wilfully acting as an Owner -Builder and am aware of the limits of my
insurance coverage for injuries to workers on my property.
N-5 2. 1 understand building permits are not required to be signed by property owners unless they are responsible for
the construction and are not hiring a licensed Contractor to assume this responsibility.
N3 3. 1 understand as an "Owner -Builder' 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.
4. 1 understand Contractors are required by law to be licensed and bonded in California and to list their license
numbers on permits and contracts.
NS 5.1 understand if I employ 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" understate and f deral law.
NS 6. 1 understand if I am considered ane mployer" 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 compensation for each "emp oyee." I also understand my failure to abide by these laws may subject
me to serious financial risk.
P -S 7. 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.
A_J8. I 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 b any subsequent owner(s) that result from any latent construction
defects in the workmanship or materials.
OwnerBuilde7Fonn 2010.doc revised 04/14/10
�S. 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 AccLdents' 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.
AS 10.1 am aware of and consent to an Owner -Builder building permit applied for in my name, and understand that I
amthe party legally and financially responsible for proposed construction activity at the site address listed above.
ft_ 1 I. 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.
A-'12. 1 agree to notify the issuer of this f
information I have provided on this form. Li
you contract with someone who does not h
assist you with any financial loss you may
Contractors may be in civil court. It is also i
employee of that individual or firm is injure(
you obtain a permit as Owner -Builder and
those Contractors are properly licensed an
CONSTRUCTION LENDING AGENCY
(DIRECTIONS: Please complete the following
I hereby affirm that there is a construction
(Sec 3097 Civ.)
Lender Name:
rm immediately of any additions, deletions, or changes to any of the
ansed contractors are regulated by laws designed to protect the public. If
ve a license, the Contractors' State License Board may be unable to
(stain as a result of a complaint. Your only remedy against unlicensed
iportant for you to understand that if an unlicensed Contractor or
while working on your property, you may be held liable for damages. If
ish to hire Contractors, you will be responsible for verifying whether or not
the status of their workers' compensation insurance coverage.
lending; agency information.)
agency for the performance of the work for which this permit is issued
Lender Address:
Before a building permit can be issued, this' orm 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 signature. _
Property Owner's Signature: � `� Date: J I-6
--------------------------------------------------------' ------------------------------------------------------------------------------------
(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).
W
Excluding the Notice to Property Owner, the e
authorize the following person(s) to act as my
Owner -Builder Permit for my project.
Scope of Construction Project (or Description
Project Location or Address: -)-b 7 `% O
Name of Authorized Agent:
Address of Authorized Agent: ;Q Z ?i J 0
I declare under penalty of perjury that I am the
above information and certify its accuracy. Not
verification acceptable to the city may be requi
signature.
Property Owner's Signature:
PERTY OWNER'S BEHALF
cution of which I understand is my personal responsibility, I hereby
lent(s) to apply for, sign, and file the documents necessary to obtain an
Work): lti4',�7ily Z)
Tel No �Py - ¢1, 4 _5030
A q5 -a/11-
operty owner for the address listed above and I personally filled out the
A copy of the property owner's driver's license, form notarization, or other
I to be presented when the permit is issued to verify the properly owner's
150.1- Date:
OwnerBuilderFo m 2010.doc revised 04114110
DocuSign Envelope ID: 9BD59E8C-5713-4A60-91 F9-7A0l3B34D2F43
CUPERTINO
JOB ADDRESS: 0
PERMIT
ON
,GENERAL CONTRAC-fOR: BUSINESS INCENSE #
ADDRESS: CITY/ZIPCODE:
Building Department
Cit,• Of Cupertino
1
10303 Torre Avenue
Cupertino, CA 95014-325
Telephone 408-777-32128
Fax: 408-777-3333
*Our municipal code requires all businesses working in the city to have a City of Cupertino business I . icense.,
NO BUILDING FINAL OR FINAL OCCUPANCY IN WILL BE SCHEDULED UNTIL THE
GENERAL CONTRACTOR ANDALL SUBCONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO
BUSINESS LICENSE.
I am not using any subcontractors:
Signature
Please check- applicable subcontractors and complete the following information:
DocuSigned by:
'7 1--
'�--D4B91591 fffter / Contractor Signature
zn-
7/13/2016
Date
SUBCONTRACTOR
BUSINESS NAME
BUSINESS ,LICENSE #
Cabinets & Millwork
Cement Finishing
Electrical
Excavation
2 -
Fencing
Flooring Carpeting
Linoleum Wood
Glass I Glazing
1
Heating
Insulation
Landscaping
Lathing
Masonry
Painting Wallpaper
Pavin-
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
DocuSigned by:
'7 1--
'�--D4B91591 fffter / Contractor Signature
zn-
7/13/2016
Date