B-2016-2286 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2016-2286
22170 BERKELEY CT CUPERTINO,'CA 95014(326 12 033) ANTHONY LEWIS
INCORPORATED
SAN JOSE,CA 95125-
1618
OWNER'S NAME: SHETTY SURAJ TRUSTEE&ET AL DATE ISSUED:07/11/2016
OWNER'S PHONE:408-888-4347 PHONE NO:(408)217-8621
LICENSED CONTE ACTOR'S DFCYAR ATION BUILDING PERMIT INFO;
License Class B:C-10 Lic.#851107
Contractor ANTHONY LEWIS INCORPORATED Date 08/31/2017 X BLDG X ELECT_PLUMB
_
I hereby affirm that I am licensed under the provisions of Chapter 9(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:
I hereby affirm under penalty of perjury one of the following two declarations: (1)EV CHARGING STATIONS(2)(50 AMPS)-GARAGE
1. I have and will maintain a certificate of consent to self-insure for Worker's REV#1-REMOVING(E)200 AMP PANEL REPLACING WITH(I)200
Compensation,as provided for by Section 3700 of the Labor Code,for the AMP PANEL-8/11/2016
-performance of the work for which this permit is issued.
f:.="I have and will maintain Worker's Compensation Insurance,as provided for by
,.'®:,f Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued. Sq.Ft Floor Area: Valuation:$3500.00
APPLICANT CERTIFICATION
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 326 12 033
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 a will comply with all non-point
source regulations per the Cupertino nicipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
s..
Signature Date 8/25/2016 Issued by:AbbyAyende
Date:07/11/2016
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law 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
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 intended or offered for inspection.
sale(Sec.7044,Business&Professions Code)
2. I,as owner of the property,am exclusively contracting with licensed Signature of Applicant:
contractors to construct the project(See.7044,Business&Professions Code). Date:8/25/2016
I hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
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. 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 the work for which this California Health&Safety Code,Sections 25505,25533,and 25534. 1 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 making this certificate of will maintain compliance with the Cupertino Municip ode,Chapter 9.12 and
exemption,I become subject to the Worker's Compensation provisions of the the Health&Safety Code,Sec'ons 25505 33,and 25534.
Labor Code,I must forthwith comply with such provisions or this permit shall
be deemed revoked. 1,-Owner or authorized agent:
APPLICANT CERTIFICATION Date:8/25/2016
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 be used
D ARATION
Code,Section 9.18. I understand my plans shall bused as public records.
Licensed
Signature Date 8/25/2016 Professional
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255
III B
CUPERTfNd (408)777-3228•FAX(408)777-3333•buildinclacupertino.org
❑NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION/TI REVISION/DEFERRED ORIGINAL PERMIT# Q-210111-Z2S�
PROJECT ADDRESS 9-1110 C4, APN#
.OWNER NAME PHO f{() TsS'&' y3`f.� EMS5�1L, (OS
o0Vt)' ft,1.CoI'1'1. .
SAIL
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STREETADDRESS^^L 1,70
{�Q'� CA. ... CITQSY, ,ZIP STA CA q14ll n^Lq. . FAX
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CONTACT NAME P NE E-MAIL
{�a\Ii �Jeven G qso-- +meq rtevc�e7a.^l,on Itwis Y\c.com
STREET ADDRESS .CITY,STATE,ZIP FAX -
3� Auzvo;is Ax Sah J e Cil TSI z(o
❑OWNER ❑ OWNER-BUILDER ❑ OWNERAGENT ❑ CONTRACTOR V CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT
CONTRACTOR NAME LICENSE NUM ER LICENSE TYPE BUS.LIC#
/v r Le Slle ca0 (o!70
COMPANY NAMEE-�IL FAX
nk�\01\ I�e1>Jts Zre. AItWtS a7 Lv\�\oI\ ftw\t1Ar—co r,
STREET ADDRESS 14H Aurtws ASC CI'!_q A�'EC� CA qS I'Z� P O�jNE :
``66. uiU1 CJ' .+C a'1(��. O��l
ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC
COMPANYNAME, E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
DESCRIPTION OF WORK Q ` G lkl��I �Q1`l\ MCA ydV" k C�s.11 L.: 50 An:t
IJ
TJ` 1 W CIS Afkl Ct `4 I 1T•. yv\a\). •,.iA _.
EXISTINGUSE PROPOSED USE CONSTR TYPE #STORIES
USE TYPE OCC. SQ.FT. VALUATION($)
EXISTG NEW FLOOR DEMO TOTAL
AREA AREA AREA NET AREA
BATHROOM KITCHEN OTHER REMODEL AREA REMODEL AREA REMODELAREA
PORCH AREA - DECK AREA TOTAL DECK/PORCH AREA GARAGE AREA: DETACH
❑ATTACH
#DWELLING UNITS: IS A SECOND UNIT []YES SECOND STORY []YES
BEING ADDED? []NO ADDITION? [:]NO
PRE-APPLICATION ❑YES IF YES,PROVIDE COPY OF IS THE BLDG AN. ❑YES TOTAL TOTAL.VALUATION:
PLANNINGAPPL# []NO PLANNING APPROVAL LETTER EICHLER HOME? ❑NO •'" i� " - •�j
606
By my signature below,3 certify to each of the following: I am the property owner or authorized agent to act on the property 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 buil ` g constructi n. authorize representatives of Cupertino to enter the above-identified property for inspection purposes.
Signature of Applicant/Agent: Date: S 1 A�
v �r rN' •'IDT,FI s...; i.,..v�.2.
SUPPLEMENTAL INFORMATION REQUIRED
New SFD or Multifamily dwellings: Apply for demolition permit for r M m "
1
— I�", UY1C:R,'rEIG-'GS1I�t;l����. F �`� .B'(7�11DJN4�r.A1\33tEW 4Q`
existing building(s). Demolition permit is required prior to issuance of building v
permit for neve building. C[ �ruan+I6An� �
r n x
Commercial Bldgs: Provide a completed Hazardous Materials Disclosure A7VD Iris
form if any Hazardous Materials are being used as part of this project. zl,l FAEPT
Copy of Planning Approval Letter or Meeting with Planning prior to *k
submittal of Building Permit application. ;� w
BldgApp 2011.docrevised 06121111
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2016-2286
22170 BERKELEY CT CUPERTINO,CA 95014(326 12 033) ANTHONY LEWIS
INCORPORATED
SAN JOSE,CA 95125-
1618
OWNER'S NAME: SHETTY SURA)TRUSTEE&ET AL DATE ISSUED:07/11/2016
OWNER'S PHONE:408-858-4347 PHONE NO:(408)217-8621
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class ELECTRICAL Lic.#$51107
Contractor ANTHONY LEWIS INCORPORATED Date 08/31/2017 X BLDG _ELECT -PLUMB
I hereby affirm that I am licensed under the provisions of MECH X RESIDENTIAL Chapter 9(commencing — — _COMMERCIAL
with Section 7000)of Division 3 of the Business&Professions Code and that my
license is in full force and effect. JOB DESCRIPTION:
(N)EV CHARGING STATIONS(2)(50 AMPS)-GARAGE
I hereby affirm under penalty of perjury one of the following two declarations:
1. I have and will maintain a certificate sof consent to self-insure for Worker's
Compensation,as provided for by Section 3700 of the Labor Code,for the
performance ofthe 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:$3500.00
APPLICANT CERTIFICATION
1 certify that 1 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 326 12 033
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 PECTION.
Signature'f Date 07/11/2016 Issued
Date:07/11/2016
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from.the Contractor's License Law 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
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 intended or offered for inspection.
sale(Sec.7044,Business&Professions Code)
2. I,as owner of the property,am exclusively contracting with licensed Signature ofApplicant:
contractors to construct the project(Sec.7044,Business&Professions Code). Date:07/11/2016
I hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
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. 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 the 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. 1 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 making this certificate of will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and
exemption,I become subject to the Worker's Compensation provisions of the the Health&Safety Code,Sections 25505,25533,and 25534.
Labor Code,I must forthwith comply with such provisions or this permit shall
be deemed revoked.
Owner or authorized agent:
APPLICANT CERTIFICATION Date:07/11/2016
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 07/11/2016 Professional
ALTERNATIVE ENERGY PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255
(408)777-3228• FAX(408)777-3333•building(a)-cupertino.org
CUPERTINOPROJECT ADDRESS �L!ry (k C v ,&(•t,na L A APN# ,J Z eC I Z — 033
OWNERNAMESCCA V 1t 0-434-
'o$� T�MAIL�b 6S�I� I-CON
STREET ADDRESS FCC
STATE,ZIP FAX
2 no Ci�+ C,► ; �l ,t► CA
CONTACT NAME p E_
o�It �� 30-8 �Lewrc)omtn 6i3mL f 6rf�
STREET SS CITY,STE;ZIP 'I FAX
❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT
CONTRALTO NAME r W.I LIV� NN UMBER LIC,,�'N,StE�TYPE BUS.LIC#7/ �� h
COMP ,NAME 1 (J� E-�t D �1 L1 ISL' F� Jk7 V
1_Gwlf C lGwifW An Th �Cu+�tlnl+�AM
STREET ADDRESS CITY,ST TE;ZIP O
Laws Ave SAV, It
A crS17,1 /�lf V 1--667-
1
ARCHITECT/ENGINEERNAME LICENSE NUMBER BUS.LIC#
COMPANY NAME E-MAIL FAX
I Z 7
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF ❑ SFD Or Duplex ❑ Multi-Family PROSECT INWILDLAND PROJECT IN
STRUCTURE: ❑ Commercial URBAN INTERFACE AREA ❑ Yes ❑ NO FLOOD ZONE ❑ Yes ❑ NO
❑SOLAR PANELS ELECTRIC VEHICLE CHARGING STATION ❑ SOLAR WATER HEATING ❑ OTHER:
FOR SOLAR PANELS. NUMBER OF PANELS/UNITS: KILOWATTS(COMMERCIAL ONLY): TOTAL VALUATION: 31 foo
DESCRIPTION OF WORK.
ORK L C S C u NTT 'TW c u ` �. S 0 41P Ckv&
D
sr> �
By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on the property 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 ild golstruction. I authorize representatives of Cupertino to enter the abov ide 'fled property for inspection purposes.
Signature of Applicant/Agent: ' `%%/G Date: l j
SUPPLEMENTAL INFORMATION REQUIRED
d , ,OFFICTUSE ONLX
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i STANDARD
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