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B-2016-3277CITY OF CUPERTINO BUILDING PERMIT BUILDINGADDRESS: CONTRACTOR: PERMIT NO: B-2016-3277 21771 STEVENS CREEK BLVD CUPERTINO, CA 95014-1175 (326 20 049) RONNYS INC OWNER'S NAME: CUPERTINO GAYATRI LLC OWNER'S PHONE: 415-254-4582 LICENSED CONTRACTOR'S DECLARATION License Class Sc$ Lie. #809197 Contractor RONNYS INC Date 08/31/2018 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 LOS BANOS, CA 93635 ISSUED: 03/07/2017 PHONE NO: (209) 827-9858 BUILDING PERMIT INFO: BLDG —ELECT —PLUMB MECH _ RESIDENTIAL X COMMERCIAL JOB DESCRIPTION: T.I. - ADA COMPLIANCE INCLUDING CONCRETE WORK, AND PARKING LINES Compensation, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. 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: $7000.00 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 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 thepupertino Municipal Code, Section 9.18. Date 03112017 I hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: 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. 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 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 03/7/2017 "N Number: Occupancy Type: 326 20 049 PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTION. 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: 03n/2ol7 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 25595, 25533, and 25534. Owner or authorized agent: Date: 03/7/2017 ` f' 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 CU -PERT -WO F] Nm commucfacm T�- CONSTRUCTION PERMIT !4171�PLICATION - 1201211hk .COMM€ NIT•Y D.EVELOPMEW.. DEPARTMENT -BUILDING DIVISION 10300 TORRE A -VENUE - CUPERTINO, CA 95014-3255 (408) 777-3226 .- FAX (408) 777-$333 - building(d) cu,nerfltio.o[q -0 ADDITION OAUTMATION./Tl 0 RENYISICINIDP.T-.r_RRUI) ORIGINALPHRMIT11 iRO1FCrAUr3R1 SS 7 7 1 STREET ADDRESS MY.M.TF.' ZIP FAX MNTACT NANIP S�.aV.ile /VeLlMa -109- 5 ooifinie_ ron, fl ra to SIREFIT ADDRESS� &r PIA A c'TytsT r.AX IT GIVINF)t 11 OWNP1141AL11ER. 13 01YINERAGENT 11:1MTRACTOP(:0M[`RAVTQXAGr 11 ARCITYPECT 13 ENGINEER El DEVELOVER OTENkWT Z. ------ __ COMPACTOkKAME - UUNSE NVIVE'10-1 117WLICPNOTY.M.6- 0 Das, LIC ti 1AA 1 11 C- (YAUIA14YNAMB Pi I 1)A VS —A L. P.'Pg ot I r n e- R NnA 115 ;4 r- - aI FAX j AIU.'Hr17(.'.T1&'qCdNI1XA NAME 1JUME-NUM13M BUS. LIC, 9 COMPANY NAME E-MAIL. 'FAX -STMEbTADDRESS CITY .'STATE ZT? ?HONS, L CA 1)4 OaLk;,Ia s M. 'rvm' -DCC. SQ.rT. VALUATIONIM .EXIS'Ecr mmm(x)m 1) E-W.TOM AREA AUX IkItUAMostr+ 'KETAXIA BATEIR0010 I C'ULER ,REMODEL ARLA REMODEL AREA # REMODELAMA P URR F1 i XR_ G TOTALDEC I a I ,A&kGBA'RL-A QD85TAC14 Ej --i DWELLING -ffxs I- rj- owis_ mFoN5-TF6WY'-'ffT9 ------ TADDITION? []NO VA&APPLICAMON ©YS-11YES, PR0Vfl*C0FY Olt 19TIM, RIAGAN E]YRS'ALVALUkTION -PLANNINGAM41 EJN() PLAMUNG APPROVALLMTER FICHLER-110AM? E3 NO By my signature below, I certify to tea of -the f'oltowing. I tan the; property owner or authorized agent to' .,t on tht property owner's behalf. I have read.this :applioaticr; and the information I have provided is coriect. I have.read the Deseription of Work and vmrify it iS amumto. I -V,m to comply-xith all appliedbIr I ocal ordinances and -state lawswinti b ilding constrmtion. 14uthor3ze representatives of Cupertino to enter the above-idenfified pToporty for inspection purposes. I d11-3416 gki'arureot`Appliomi/Agent Nl.: 7 SUPPLEMENTAL INFORMATION RE-QUIRED . ..... M NeCVSFD.OrMultifallailycl,vcllings: Apply for &molition perjlih for exisfing buildin.g(s}. Demolition permit is required prior to issuance ofbuilding "A. _p arm it for new building, Commerml Bldgs: Provide a com�li.eted Hayardous kawrhals Disclosure :form ifmiv HwArdous Materials arebeing used as part of1his pr(�;ect. Cory of Plawting Approval Jettar Cly �1,tjing 'All ill Planning prior to 7 .0. strbinttful of Building Pennit application. iz") q t 0, 1 BidgApp.j.'61 1. doe revised 06121/1 I