B-2016-2637CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS
CONTRACTOR:
PERMIT NO: B-2016-2637
10265 JUDYAVE CUP RTINO, CA 95014-3524 (375 08 043)
CRAIGA ROGERS
CONSTRUCTION INC
SAN JOSE, CA 95136
OWNER'S NAME: BA' INS KULVINDER SINGH AND SUKHVANT K TRUSTE
DATE ISSUED: 09/01/2016
OWNER'S PHONE: 4018-891-9637
PHONE NO: (408) 978-5484
LICENSED CONTRACTOR'S DE R TION
BUILDING PERMIT INFO:
License Class--B Lic. #978553
Contractor CRAIG A ROGERS CONSTRUCTION INC Date 11/30/2016
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 of perjury one of the following two declarations:
(N) TEMP POWER (100 AMP) POLE
penalty
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 pf the Labor Code, for the performance of the work for which this
Sq. Ft Floor Area:
Valuation: $500.00
permit is issued.
fl APPLICANT CERTIFICATION
I certify that I have read this application and state that the above
information is correct. 11 agree to comply with all city and county ordinances
APN Number:
Occupancy Type:
and state laws relating Ito building construction, and hereby authorize
375 08 043
representatives of thisity 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
this permit.
may accrue against applicant
City in consequence l the granting all
Additionally,thea licant understands and will comply with all non- oint
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
source reions per the Cu a �Municipal Code, Section 9,111,P
180 DAYS FROM L CTION.
Si nature -
g ` Date 09/01/2016
Issued b LISSANAMES
i
Date: 09/01/2016.
OWNER-BUILDER DECLARATION
I hereby affirm that I a I 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. 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.704z, 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: 09/01/2016
I hereby affirm under penalty of perjury one of the following three declarations:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
1. l 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. l 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 Cade, Sections 25505, 25533, and 25534. I will
is issuod.
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
permit
3. I certify that 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 defused by the Bay Area Air Quality agement District I
Worker's Coml pensation laws of California. If, after making this certificate of
I
K maintain compliance with the Cupertino Municipal ode, apter 9.12 and
exemption, become subject to the Worker's Compensation provisions of the
the Health & Safety e, Se tions 255QSr255 3, and 2 534.
Labor Code, I must forthwith comply with such provisions or this permit shall
be deemed re oked.
Owner or authorized agent:
APPLICANT CERTIFICATION
Date: 09/01/2016
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 and state laws
LENDINGAGENCY
I hereby affirm that there is a construction lending agency for the performance
relating to building construction, and hereby authorize representatives of thiscity
of work's for which this permit is issued (Sec. 3097, Civ C.)
to enter upon the abovp mentioned property for inspection purposes. (We) agree
Lender's Name
to save indemnify andeep 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.
I understand my plans shall be used as public records.
Si nature Date 09/01/2016
9
Licensed
Professional
GENERAL PERMIT APPLICATION MEF
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
CUPERTEt�t€ (408) 777-3228 • FAX (408) 777-3333 • building(a.cupertino.org
M I Sk C
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ii PROJECT ADDRESS
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CONTACT NAME i - k PHONE q C)�-_n `j yf jr x1 AIL
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❑ OA%NER ❑ OR'IQER-BL'II.DER ❑ ORTTERAGEIAT ❑CONTRACTOR 0NTRACTORAGENT ❑ ARCHITECT ❑ ENGL>\TEER. ❑ DEVELOPER ❑ TENANT
CO 1 \F- \i `' �V� `y ?��`�? V LICEN YPE BUS. LIC #-3 2— �!? 6
COMPANY NAA4E E-MAIL FAX
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6 88 -
ARCMTECTIENG..1NIER NAME I LIC NSE NUMBER BUS. LIC r
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY, STATE, ZIP PHONE
USE OF SFD or Duplex ❑ Multi -Family PROJECT -IN' VVILDLAND , PROJECT N
STRUCTURE:
EJ; Commercial URBAN,NTERFACEAREA El Yes NO I FLOOD ZONE 11 Yes 1IO
DESCRIPTION OF WORKT
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i
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TOTAL
1
By my signature below, I certify tobold
following: I amt e property owner or authorized agent to act on the property owner's behalf. I have read this
application and the infonuation I hais co ve read e ription of work and verify it is accurate. I agree to comply with all applicable local
ordinances and stat; laws relating to frac n. aut e repres tatives of Cupertino to enter the hove-identifiejd roperiy for inspection pin -poses.
Signature of Applioant/Agent: Date: t
S ME TAL INFORMATION REQUIRED r.oFFicE Ds> o;zY, ..
R7EPA1.risc,4pp_2011.dac revised 03116111