D-2017-0046CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS:
CONTRACTOR:
PERMIT NO: D-2017-0046
22552 POPPY DR CUPERTINO, CA 95014-0802 (342 12 012)
NELSON DANIEL
RAMOS
HALF MOON BAY, CA
94019
OWNER'S NAME: KABIR HUMAYUN AND NAZNEEN A
DATE ISSUED: 07/24/2017
OWNER'S PHONE: 408-981-8000
PHONE NO: (650) 834-1260
LICENSED CONTRACTOR'S DECLARATION
BUILDING PERMIT INFO -
License Class $ Lic. #79661
Contractor NELSON DANIEL RAMOS Date 06/30/2019
— BLDG —ELECT —PLUMB
MECH X RESIDENTIAL COMMERCIAL
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.
JOB DESCRIPTION
DEMO ONE STORY SFD (1682 S.F )
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
f�e ormance of the work for which this permit is issued.
�z. aaze-and will maintain Worker's Compensation Insurance, as provided for by
C ' S ction 3700 of the Labor Code, for the performance of the work for which this
Sq. Ft Floor Area:
Valuation: $7500.00
permit is issued.
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
and state laws relating to building construction, and hereby authorize
34212 012
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
PERMIT EXPIRES IF WORK IS NOT STARTED
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
source regulations per the Cupertino Municipal Code, Section 9.18.
180 DAYS FROM LAST CALLED INSPECTION.
Sig ature Date 7/24/2017
Issued by Abby ygnde
Date: 07/24/2017
OWNER -BUILDER 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:
1. I, 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.7044, Business & Professions Code)
z. 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: 7/24/2017
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
performance of the work for which this permit is issued.
HAZARDOUS MATERIALS DISCLOSURE
z. I 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 Code, Sections 25505, 25533, and 25534. I will
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
a. 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
exemption, I become subject to the Worker's Compensation provisions of the
the Health & Safety Code, Sections 25505, 25533, and 25534.
Labor Code, I must forthwith comply with such provisions or this permit shall
be deemed revoked.
Owner or authorized agent:
CERTIFICATION G
Date: 7/24/2017
APPLICANT
I certify that I have read this application and state that the above information is
CONSTRUCTION LENDING AGENCY
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 (See. 3097, Civ C.)
relating to building construction, and hereby authorize representatives of this city
to enter upon the above mentioned property for inspection purposes. (We) agree
Lender's Name
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
and will comply with all non -point source regulations per the Cupertino Municipal
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Code, Section 9.18.
Licensed
Signature Date 7/24/2017
professional
UP'ERTIN
,_01700-
DEMOLITION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 _ _
(408);.777-3228 FAX (408) 777-3333 - building o)cupertino.org
PROJECT ADDRESS.,
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OWNER ❑ OWNER -BUILDER ❑ OWNERAGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT
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DESCRIPTION OF WORK
RESIDENTIAL
#DWELLING
OFFICE
USE ONLY
' USE
OCC.
TYPE
SQ. FT.. VALUATION
J9�/y9
FLOOR AREA ( /
UNITS
COMMERCIAL
FLOOR AREA
TYPE OF CONSTRUCTION
# STORIES
-
AQMD JOB NUMBERa
RECEIVED BY: TAL 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 Piave 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 prope5ty/for inspection purposes.
Signature of Applicant/Agent: { Date: 9 �-
SUPPLEMENTAL ORMATION REQUIRED PRIOR TO IS�bANCE OF DEMOLITION PERMIT
OFFICE USE ONLY
PLAN CHECK.TYPE'
Provide Job Number from Bay Area Air Quality Management District www.baagmd.org @ 415-749-4762.
❑ ExP>ss
Provide three copies of a site plan showing protection for any trees 10" in diameter or more at 3' above grade.
❑ STANDARD,
Provide letter from PG&E (408-725-3325) stating all gas and electric has been disconnected.
❑ LARGE
,ZVIPtanning Dept clearance to verify building is not considered an historical landmark. Allow 10 business days.
t7 IvrasoR
Provide letter of clearance of all vermin from a licensed pest control contractor.
Applicant shall call the Public Works Department at 408-777-3104 and schedule a "habitable dwelling" inspection.
Provide signed Debris Bin and Recyclable Materials form.
Commercial Buildings Only: Provide Fire Dept clearance for fire suppression / alarm system review.
DemoApp_2016.doe revised 03129/16
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