B-2016-2045 CITY OF CUPERTINO PUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERM]TNO:B-2016-2045
20163 NORTHCREST SQ CUPERTINO,CA 95014-0511(316 37 001) I C R
SAN JOSE,CA 95123
OWNER'S NAME: NARAYAN LOKESH M AND URS THANUJA N 1 DATE ISSUED:08/17/2016
OWNER'S PHONE: PHONE NSD:(403)561-7690
LICENSED CONTRACTOR'S DECLARATION. BUILDING PERMIT INFO:
License Class FLOORING AND FLOOR COVERING Lia#375451
Contractor I C R Date 04/30/2017 X BLDG —ELECT _PLUD 111
I hereby affirm.that I am licensedunder 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:
OTHER,REMODEL-CONVERSION OF ATTIC SPACE INTO A LOFT
I hereby affirm under penalty of perjury one of the following two declarations: (240 S.F.);ADDING 2(N)SI" LIGHTS
1. 1 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 work for which this
permit is issued. Sq.Ft Floor Area: Valuation:$25000.00
APPLICANT CERTIFICATION
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: OCCUP2 ney Type:
and state laws relating to building construction,and hereby authorize 316 37 001
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 tF WORD IS NOT STARTED
may accrue against said City in consequence of the granting of this permit. WITHIN 18®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 CALLED INSPECTION.
Signature Date Issued by:MELISSA NAMES
Date:08/17/2016
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of the RE-ROOFS.-
following
E-ROOFS°following two reasons: All roofs shall be inspected prior t any roofing material being installed.If a roof is
1. 1,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(Sec.7044,Business&Professions Code). Date:
I hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
1. 1 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. 1 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 C pertino 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,Sectio 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 se equipment or devices which emit hazardous
air contaminants as defined by tl ie Bay Area Air Quality Management District I
Worker's Compensation laws of California., If,after making this certificate of will maintain compliance with th Cupertino Municipal Code,Chapter 9.12 and
exemption,I become subject to the Worker's Compensation provisions of the the Health&Safety Cc de,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
I certify that I have read this application and state that the above information is C NSTRUC riON LENDING AGENCY
correct.I agree to comply with all city and county ordinances and state laws I hereby affirm that there is a co istruction 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 ARCHIT CT'S DECLARATION
and will comply with all non-point source regulations per the Cupertino Municipal
Code,Section 9.18. l understand my plans shall be used as public records.
Licensed
Signature Date Professional
CONSTRUCTION PERMIT APPLICATION!
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO,CA 95014-3255
CU PERTi11 0 (408)777-.$228 a FAX(408)777-3333•building(a7cuperEino.org
I_.!NEW CONSTRUCTION E3ADDITION ❑ALTERATION I TI 0 REVISION/DUM E D C RICsMAL.PERMIT#
PRO11?CT ADDRESS® APN# �- RI
OWNER NAME PHONE EMAK #
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12 OWNER-BUILDER ® OWNER AGENT ® CONTRACTOR 13 CONTRACTOR AGENT 13 ARCHITECT 11 ENGINEER 11 DBvmOPER ❑TENANT
CONTRACTORNAME LICENSE NUMBER LICENSE TYPE BUS.LIC#
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PONE
ARCHITECURNGINEER NAME r LICENSE NUMBER BUS.LTC#
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COMPANYNAAM IL FAX
STREET ADDRESS CITY,S*t1kT ZIP PHONE
DESCRTPTION OF WORK a vas
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EXISTINGUSE PROPOSED USE - CONSTR.TYPE #STORMS
USE TYPE C cc. sQ.rT, VALUATION(�)
EXISTG NEW FIAOR - DEMO TOTAL
AREA AREA AREA NETAREA
BATHROOM KrMCHEN OTHER
REMODEL AREA REMODEL AREA REMODEL AREA
PORCH ARLA DECx`S.ATtPA TOTAL DECXJPORCII AREA GARAGEAREAI HDRTACH
ATTACH
#DWELE.WG ONUS: IS A SECOND UNIT ®YES SECOND STORY [JYES
BEINGADDFM? []NO ADDITION? []NO n ,I
PRE-APPLICATION [ YES IF YES,PROVIDE COPY OF IS THS BLDG AN []YES RECEIVED BY: TOTAL VALUATION,
PLANNINGAPPL# [:]NO PLANNING APPROVAL LETTER ETCHLERHOIVIE? ®No
By my signature below,I certify to each of the following: I am the property owner or authorized agent to act o e property owner's behalf, I had a 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'o comply rwi¢.h all applicable local
ordinances and state laws relating to' 'din co trtion. I authorize representatives of Cupertino to enter the above-identif d praper v for inspection purpases.
Signature of ApplicanUAgerst: Date:
sUPPLENIEN OT191kTION REQUIREDPI aIv.cHFcI�TYr> ROUTIN SU.P
kv
New SFID or Multifamily divU Ings: Apply for demolition permit for ❑ ovEn-THE tt ouN� IIUaI DII tLtiNvvl>w
existing building(s). Demolition permit is required prior to issuance of building
permit for new building. D EXPRESS �rLArTlv�va PI Aril Ias1 vlEdv
_Commercial Bldgs: Provide a completedhazardous Materials Disclosure ❑ sTANDAHn ® AuBalc i�olrxs
Form if any Hazardous Materials are being used as part of this project. ❑_LARGE DEPT
_Copy of Planning ApprovalLefter or Meeting with Planning prior to MAJOR p yANfTARV 8FV&2DISTRICT
submittal of Building Permit application.
EN-VIROMiENTAL IMALTH
: k4g-App 2011.doe revised 06121111