B-2016-3183CITY OF CUPERTINO BUILDING PERMIT
BUILDINGADD SS:
10673 MORENGCI DR CUPERTINO, CA 95014-3513 (375 34 015)
OWNER'S NAME: VARSHNEYARUN AND GUPTAANURADHA
OWNER'S PHONE: 408-464-5870
License Class Lic. #
Contractor OWNER/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.
2. I have and will maintain Worker's Compensation Insurance, as provided for by
Section X700 of the Labor Code, for the performance of the work for which this
permit is issued.
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
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 regulation$ per the Cupertino Municipal Code, Section 9.18.
Signature Date11/ 7/2017
OWNER-BUI •DtltDECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of the
following two reasons:
i. I, as owner of the properly, or my employees with wages as their sole
compensation, will do the work, and the structure is not intended or offered for
sale (Se6.7044, Business & Professions Code)
J 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.
2. I have and will maintain Worker's Compensation Insurance, as provided for by
Section $700 of the Labor Code, for the performance of the work for which this
permit is issued.
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 shall
be deemed revoked.
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 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, sand expenses which may accrue against said City in
consequence of the granting of this permit. Additionally, the applicant understands
and will corpply with all non -point source regulations per the Cupertino Municipal
Code, Sec iop 9.118.
Date 1/17/2017
CONTRACTOR: PERMIT NO: B-2016-3183
OWNER/BUILDER
DATE ISSUED: 01/17/2017
PHONE NO:
BUILDING PERNHT INFO:
X BLDG —ELECT _ PLUMB
_ MECH X RESIDENTIAL _ COMMERCIAL
JOB DESCRIPTION:
TO CLEAR CODE CASE: CONVERT CARPORT TO DETACHED ONE
CAR GARAGE (222 S.F.); REMOVE ATTACHED STORAGE (92 SQ
FT).
Sq. Ft Floor Area: I Valuation: $20000.00
"N Number: Occupancy Type:
375 34 015
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
Issued by: Kim Dunbar
RE -ROOFS:
All roofs shall be inspected,prior to any roofing material being installed. If a roof is
installed without first obtaining an inspection, I agree to remove all new materials for
inspection.
Signature of Applicant:
Date: 1/17/2017
ALL ROOF COVERINGS TO BE CLASS "A"
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 a Cupertino Municipal Code, Chapter 9.12 and
the Health & Safety 0e, Secti ns 25505, 25533, and 25534.
Owner or authorized age f-
Date: 1/17/2017
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
I understand my plans shall be used as public records.
Licensed
Professional
+CUPERTIN:O
F1 NEW CONSTRUCTION
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(4088)) 777-3228 • FAX (408) 777-3333 • buildiinng ancupertino.orq
I I ADDITION %AT.TFR ATTON / TT I. I RRVTST0N / T)F , 0-:F -rFT) 0RTC:TNAT. PFRMTT #
PROJECTADDRESS10673 Morengo Dr Cupertino CA,
APN#
OWNERNAMEArun Varshney / Anuradha 7PHONE
GlIptA
408464-5870
E M�Lanuhomes@gmaiLcom
STREET ADDRESS 10388 lansdale Ave
CITY, STATE, ZIP Cupertino , CA,
FAX
CONTACT NAME Anu Gupta
PHONE4084645870
E-MAILanuhomes@gmail.com
STREET ADDRESS Same as above
CITY, STATE, ZIP
FAX
WNER ❑ 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
ARCHITECT/ENGINEER NAME Felix Lorezo
LICENSE NUMBER
BUS. LIC #
COMPANY NAME
E-MAIL
FAX
STREET ADDRESS
CITY, STATE, ZIP
PHONE 4085066578
DESCRIPTION OF WORK Non -confirming carpo t,t0_non, confirming -_one-car - - - "-
garage
EXISTING USE
PROPOSED USE
CONSTR. TYPE
# STORIES
one car grage
one car garage
USE
TYPE
OCC.
SQ.FT.
VALUATION ($)
EXISTG
NEW FLOOR
DEMO
TOTAL
AREA
AREA
AREA
NET AREA
BATHROOM
KITCHEN
OTHER
REMODEL AREA
REMODEL AREA
REMODEL AREA
PORCH AREA
I DECK AREA
TOTAL DECKTORCH AREA I GARAGE AREA:TACH
AT1214
# DWELLING UNITS:
IS A SECOND UNIT ❑ YES
SECOND STORY []YES
�REINGADDED? [:]NO
ADDITION? [:]NO
PRE -APPLICATION ❑ YES IF YES, PROVIDE COPY OF
IS THE BLDG AN ❑ YES
RECEIVED 13(�,
TOTAL VALUATION:
PLANNING APPL # NO PLANNING APPROVAL LETTER
EICHLER HOME? []NO
By my signature below, I certify to eac of the following: I am the property owner or authorized agent to act n the property owner's behalf. have read this
application and the inforniation I have x ided is correct. I havejcad the Description of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating to bul di g construction. I orize representatives of Cupertino to enter the above -identified property for inspection purposes.
6
Signature of Applicant/Agent: Date:
SUPPLEMENTAL O ATION REQUIRED
PLAN CTTECK TVPE"
ROUTING SUP_
OVEx-THE-COUNTER -
E l BUILDING PLAN REVIEW
New SFD or Multifamily dwellings: Apply for demolition permit for
_
existing building(s). Demolition permit is required prior to issuance of building
�"
permit for new building.
❑ EXPRESS ."
PLANNING.PLAN:REV.IEW ,'t
Commercial Bldgs: Provide a completed Hazardous Materials Disclosure
❑, "STANDARD'
1] PUBLIC WORKS,
_
form if any Hazardous Materials are being used as part of this project.
El "LARGE "
(] •FIRE VErT
_ Copy of Planning Approval Letter or Meeting with Planning prior to
El MAJOR
El- SANITARY SEWER DISTRICT" -
submittal Of Building Permit application.
❑ ENVIRONMENTAL HEATTH
BIdgApp_2011.doc revised 06/21/11
CUPERTINO
OWNER -BUILDER DISCLOSURE FORM
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228 • FAX (408) 777-3333 - building()-cupertino.org
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 ADDRESS 1 p _7S ("+ 5fj �� Q
�(t9-ts%
APN
BP#
OWNER NAME Amyl Varchnfj
OWNER ADDRESS to g gS La of d e- e co „
`-�
DESCRIPTION OF WORK: _-7,4 60 a Q /� QyJ Yt. ` a yu l y
We are providing you with an Owner -Builder Acknowledgment 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.
OWNER'S ACKNOWLEDGMENT AND VERIFICATION OF INFORMATION
(DIRECTIONS: Please read and initial each statement below to signify you understand or verify this information.)
1. 1 understand a frequent practice of unlicensed 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. 1, as amOwner, Builder; -maybe -held liable=and subjett-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 willfully acting as an Owner -Builder and am aware of the limits of my
insurance coverage for injuries to workers on my property.
WV 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.
3. 1 understand as an "Owner -Builder" I 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.
A�L4. I understand Contractors are required by law to be licensed and bonded in California and to list their license
numbers on permits and contracts.
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' under state and federal law.
6. 1 understand if I am considered an "employer" 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 "employee." I also understand my failure to abide by these laws may subject
me to serious financial risk.
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.
8. 1 understand as an Owner -Builder if I sell the property for which this permit is issued, I may be held liable for
Ty financial or personal injuries sustained by any subsequent owner(s) that result from any latent construction
defects in the workmanship or materials.
OwneYBuildeYForm 2010. doe revised 04/14/10
K9. I understand I may obtain more information regarding my obligations as an "ampNyo/ fnomthe Internal
Revenue Service, the United States Small Business Administration, the California Department nfBenefit Payments,
and the California Division of Industrial Accidents. I also understand I may contact the California Contractors' State
License Board (CSLB)ot1-8OO-321-C8LB/2752\orvvwxw.co|b.oa.govfor more information about licensed
contractors.
V-1 0. 1 am aware of and consent to an Owner -Builder building permit applied for in my name, and understand that I
am the party legally and financially responsible for proposed construction activity at the site address listed above.
N11. 1 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.
I agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the
information | have provided onthis form. Licensed contractors are regulated by laws designed to protect the public. If
you contract with someone who does not have a license, the Contractors' State License Board may be unable to
assist you with any financial loss you may sustain as a result of a complaint. Your only remedy against unlicensed
Contractors may be in civil court. It is also important for you to understand that if an unlicensed Contractor or
employee of that individual or firm is injured while working on your property, you may be held liable for damages. If
you obtain a permit as Owner -Builder and wish to hire Contractors, you will be responsible for verifying whether or not
those Contractors are properly licensed and the status of their workers' compensation insurance coverage.
CONSTRUCTION LENDING AGENCY
(DIRECTIONS: Please complete the following construction lending agency
| hereby affirm
that there imoconstruction lending agency for the performance ofthe work for which this permit inissued
(Sec 3097 Civ.)
Lender Name:
Lender Address:
Before a building permit can be issued, this form must be completed and signed by the property owner and
returned t t4e _of the property owners driver!s-_Iicen;�
py responsible for issuing the permit. - te:,,A copy
form notarization ' or other Ven-fic-ation ac ��6]b_16to -the city maybe required to be presented when the permit is issued
to verify the property owner's signatureN
Property Owner's Signature: Date: 7� a � ;A4
'--'------------'-----------------------------------------
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agent ofthe property owner &rapply for mconstruction permit for th*(]wmepBuilden.
AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF
the Notice to OVvD theeXacV� ofvVhuh|understand isnJy du|hereby
authorize��~thefoUovvngpa Propertyn`�)bzact/ennyagent0s\toapp|yfor,e|gn^andfihathedonunnentaneoeusarytoobbanan
Owner -Builder Permit for myproject.
Scope ofConstruction Project (or Description ofVork):
Project Location or Address:
Name ofAuthorized Agent:
Address of AuthorizedAgent:
I declare under penalty of perjury that am the property owner for the address listed above and | personally filled out the
above information and certify its accuracy. 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
Property Owner's re:
Date:
OwnerBuilderFonn_2010. doe revised 04114110