D-2016-0411CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS:
10645 STEVENS CANYON RD CUPERTINO, CA 95014-3941 (342 16 134)
OWNER'S NAME: DEWAN JAHANGIR H AND ISLAM FAWZIA J TRUSTEE
OWNER'S PHONE: 408-391-0521
LICENSED CONT A TOR' DECLARATION
License Class Lic. #
Contractor HOMEOWNER/BUILDER Date
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 and that my
license is in full force and effect.
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.
z. 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.
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
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
may accrue against said City in consequence of the granting of this permit.
Additionally, the applicant understands and will comply with all non -point
source regulations per the Cupertino Municipal Code, Section 9.18.
Signature Date 9/8/2016
I hereby affirm that I am exempt from the Contractor's License Law for one of the
following two reasons:
r. I, as owner of the property, or my employees with wages as their sole
compensation, will do the work, and the structure is not intended or offered for
sale (Sec.7044, Business & Professions Code)
I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec.7044, Business & Professions Code).
I hereby affirm under penalty of perjury one of the following three 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.
z. 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.
a. 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
Worker's Compensation laws of California. If, after making this certificate of
exemption, I become subject to the Worker's Compensation provisions of the
Labor Code, I must forthwith comply with such provisions or this permit sball
be deemed revoked.
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 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 may accrue against said City in
consequence of the granting of this permit. Additionally, the applicant understands
and will comply with all non -point source regulations per the Cupertino Municipal
Code, Section 9.18. ,
Signature Date 9/8/2016
CONTRACTOR: I PERMIT NO: D-2016-0411
HOMEOWNER/BUILD
ER
DATE ISSUED: 09/08/2016
PHONE NO:
BUILDING PERMIT INFO:
—BLDG —ELECT _ PLUMB
_ MECH X RESIDENTIAL _ COMMERCIAL
JOB DESCRIPTION:
DEMO EXISTING HOME (1232 S.F.); DETACHED GARAGE (390 S.F.)
Sq. Ft Floor Area: I Valuation: $12000.00
APN Number: Occupancy Type:
342 16 134
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
Issued by: Abby Ayende
Date: 09/08/2016
RE -ROOFS:
All roofs shall be inspected prior to any roofing material being installed. If a roof is
installed without fust obtaining an inspection, I agree to remove all new materials for
inspection.
Signature of Al
Date: 9/8/2016
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
HAZARDOUS MATERIALS DISCLOSURE
I have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533, and 25534. I will
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
Health & Safety Code, Section 25532(a) should I store or handle hazardous
material. Additionally, should I use equipment or devices which emit hazardous
air contaminants as defined by the Bay Area Air Quality Management District I
will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and
the Health & Safety Code, Sections 25505, 25533, and -25534.
Owner or authorized agent:
Date: 9/8/2016
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance
of work's for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
Lender's Address
ARCHITECT'S DECLARATION
understand my plans shall be used as public records.
Licensed
CUPERT`lNO
DEMOLITION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228 • FAX (408) 777-3333 • building(a1cupertino.oM
PROJECT ADDRESS
APN # 1)42- Hp
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❑ OWNER OWNER -BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME
LICENSE NUMBER
LICENSE TYPE
BUS. LIC #
COMPANY NAME
E-MAIL
FAX
STREET ADDRESS
CITY, STATE, ZIP
PHONE
/
DESCRIPTION OF WORK ) / a
RESIDENTIAL '
# DWELLING
_ OFFICE USE ONLY
LSE
OCC,
TYPE
SQ. FC.
VALUATION
FLOOR AREA _
UNITS
COMMERCIAL
FLOOR AREA
TYPE OF CONSTRUCTION # STORIES -
AQMD JOB NUMBER J #.��^
RECEIVED BY' VVa
TOTAL VALUATION:
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 re1ad 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 buildingcpnstruction. I m4hotize representatives of Cupertino to enter the abovedeqtified property for inspection purposes.
Signature ofApplicant/Agent: Date:
SUPPLEMENTAL INFORMA N REQUIRED PRIOR TO ISSUANCE OF DEMOLITION PERMIT
OFFICE USE ONLY
PLAN CHECK TYPE
]( Provide Job Number from Bay Area Air Quality Management District www.baaamd.org @ 415-749-4762.
Provide three copies of a site plan showing protection for any trees 10" in diameter or more at 3' above grade.
❑ EXPRESS
❑ STANDARD
Provide letter from PG&E (408-725-3325) stating all gas and electric has been disconnected.
❑ LARGE
Planning Dept clearance to verify building is not considered an historical landmark. Allow 10 business days.
❑ MAJOR
Provide letter of clearance of all vermin from a licensed pest control contractor.
Works Department at 408-777-3104 and schedule a "habitable dwelling" inspection.
Y Ap licant sh�� 1 tl���
�
Provide Cons ction and Demolition Recycling Diversion signature form.
Commercial Buildings Only: Provide Fire Dept clearance for fire suppression / alarm system review.
DemoApp_M6.doc revised 05110116