B-2017-1016CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS:
7636 WEST HILL IN CUPERTINO, CA 95014-5057 (362 27 024)
CONTRACTOR:
RELIABLE & LOYAL
PERMIT NO: B-2017-1016
CONSTRUCTION
MANAGEMENT
CAMPBELL, CA 95008
OWNER'S NAME: PAMU PRIYATHAM AND PITTA HIMABINDU
DATE ISSUED: 06/26/2017
OWNER'S PHONE: 408-338-8295
PHONE NO: (408) 509-2602
LICENSED CONTRACTOR'S DECLARATION
BUILDING PERMIT INFO:
License Class @ Lic. #916332
Contractor RELIABLE 8; LOYAL CONSTRUCTION MANAGEMENT Date
X BLDG X ELECT _ PLUMB
_ MECH X RESIDENTIAL _ COMMERCIAL
05/31/2018
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
JOB DESCRIPTION:
license is in full force and effect.
TEMPORARY POWER POLE (200 AMPS)
I hereby affirm under penalty of perjury one of the following two declarations:
t. 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.
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: $500.00
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above
APN Number:
Occupancy Type:
information is correct. I agree to comply with all city and county ordinances
362 27 024
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
PERMIT EXPIRES IF WORK IS NOT STARTED
City of Cupertino against liabilities, judgments, costs, and expenses which
may accrue against said City in consequence of the granting of this permit.
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
Additionally, the applicant understands and will comply with all non-point
180 DAYS FROM LAST CALLED INSPECTION.
source regulations per the Cupertino Municipal Code, Section 9.18.
Issued by: Abby Ayende
Signature 1 Date 6/26/2017
Date: 06/26/2017
OWNER-B TIL D R DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of the
RE-ROOFS:
All roofs shall be inspected prior to any roofing material being installed. If a roof is
following two reasons:
installed without fust obtaining an inspection, I agree to remove all new materials for
t. I, as owner of the property, or my employees with wages as their sole
inspection.
compensation, will do the work, and the structure is not intended or offered for
sale (Sec.7044, Business & Professions Code)
Signature ofApplicant:
2. I, as owner of the property, am exclusively contracting with licensed
Date: 6/26/2017
contractors to construct the project (Sec.7044, Business & Professions Code).
I hereby affirm under penalty of perjury one of the following three declarations:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
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
HAZARDOUS MATERIALS DISCLOSURE
performance of the work for which this permit is issued.
I have read the hazardous materials requirements under Chapter 6.95 of the
2. I have and will maintain Worker's Compensation Insurance, as provided for by
California Health & Safety Code, Sections 25505, 25533, and 25534. I will
Section 3700 of the Labor Code, for the performance of the work for which this
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
permit is issued.
Health & Safety Code, Section 25532(a) should I store or handle hazardous
3. I certify that in the performance of the work for which this permit is issued, I
material. Additionally, should I use equipment or devices which emit hazardous
shall not employ any person in any manner so as to become subject to the
air contaminants as defined by the Bay Area Air Quality Management District I
Worker's Compensation laws of California. If, after making this certificate of
will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and
the Health & Safety Code, Sections 25505, 25533, and 25534.
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
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be deemed revoked.
Owner or authorized agent:
Date: 6/26/2017
APPLICANT CERTIFICATION
CONSTRUCTION LENDING AGENCY
I certify that I have read this application and state that the above information is
I hereby affirm that there is a construction lending agency for the performance
correct. I agree to comply with all city and county ordinances and state laws
of work's for which this permit is issued (Sec. 3097, Civ C.)
relating to building construction, and hereby authorize representatives of this city
Lender's Name
to enter upon the above mentioned property for inspection purposes. (We) agree
to save indemnify and keep harmless the City of Cupertino against liabilities,
Lender's Address
judgments, costs, and expenses which may accrue against said City in
consequence of the granting of this permit. Additionally, the applicant understands
ARCHITECT'S DECLARATION
TION
and will comply with all non-point source regulations per the Cupertino Municipal
I understand my plans shall be used as public records.
Code, Section 9.18.
Licensed
Signature Date 6/26/2017
Professional
'6-Z'0t4' mu
GENERAL PERMIT APPLICATION M E P
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
CUPERTIN4
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(408) 777-3228 •FAX (408) 777-3333 • building(U?cupertino.org
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USE OF FD I DUPLEX ❑ MULTI -FAMILY
BUILDING: ❑COMMERCIAL
PROJECT IN WILDLAND ❑ YES
URBAN INTERFACE AREA
PROJECT IN ❑ YES
IS THE BLDG AN ❑ YF.S
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TOTAL VALUATION: A 1 S U
RECEIVED BY:
By my signature below, I certify to each of the following. I am the property owner or authorized agent to act on the property owne s behalf I have 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 to comply with all applicable local
ordinances and state laws relating to building construction. I authorize representatives of Cupertino to enter the above -identified property for inspection purposes.
Signature of Applicant/Agent: . �
Date: lrJ / �� /1-7
SUPPLEMENTAL INFORMATION
REQUIRED
OFFICE USE ONLY
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AIEPMiscApp_201 1. doe revised 06/21/11