B-2017-1343CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS:
CONTRACTOR:
PERMIT NO: B-2017-1343
10640 TUGGLE PL CUPERTINO, CA 95014-3628 (375 34 067)
ROCHNS COMPANY
SAN JOSE, CA 95125
OWNER'S NAME: SINGH RANJANA TRUSTEE
DATE ISSUED: 08/14/2017
OWNER'S PHONE: 408-813-8530
PHONE NO: (408)593-7405
LICENSED CONTRACTOR'S DECLARATION
BUILDING PERMIT INFO:
License Class B. C20 Lic. #$12112
Contractor ROCHNS COMPANY Date 02/28/2019
X BLDG X ELECT _PLUMB
MECH X RESIDENTIAL
I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing
—COMMERCIAL
with Section 7000) of Division 3 of the Business & Professions Code and that my
license is in full force and effect.
JOB DESCRIPTION:
(N) TEMPORARY POWER POLE (125 AMP)
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
10* ompensation, 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: $850.00
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
APN Number:
Occupancy Type:
and state; laws relating to building construction, and hereby authorize
375 34 067
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 applica understands and will comply with all non -point
gulations pe a Cupertino Muni a C , ction 9.18.
slhnatw
180 DAYS FROM LAST CALLED INSPECTION.
Date 8/14/2017
Issued by: Jasmine Archbold
Date: 08/14/2017
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of the
RE -ROOFS:
following two reasons:
All roofs shall be inspected prior to any roofing material being installed. If a roof is
2. 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)
2. I; as owner of the property, am exclusively contracting with licensed
Signature ofApplicant:
contractors to construct the project (Sec.7044, Business & Professions Code).
Date: 8/14/2017
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
2. 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. 1 will
permit is issued.
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
3. I certify that in the performance of the work for which this permit is issued, I
Health & Safety Code, Section 25532(a) should I store or handle hazardous
shall not employ any person in any manner so as to become subject to the
material. Additionally, should I use equipment or devices which emit hazardous
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 unicipal Code, Ch Wer 9.12 and
exemption, I become subject to the Worker's Compensation provisions of the
fte Health &Safety Code, Secti 25505,�L: .
Labor Code, I must forthwith comply with such provisions or this permit shall
be deemed revoked.
O r authorized agent.
APPLICANT CERTIFICATION
8 14 20
I certify that I have read this application and state that the above information is
CONSTRUCTION LENDING AGENCY
correct. I agree to comply with all city and county ordinances and state laws
I hereby affirm that there is a construction lending agency for the performance
relating to building construction, and hereby authorize representatives of this city
of work's for which this permit is issued (Sec. 3097, Civ C.)
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,
judgments, costs, and expenses which may accrue against said City in
Lender's Address
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
Code, Section 9.18.
1 understand my plans shall be used as public records.
Signature Date 8/14/2017
Licensed
Professional
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE'AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228 - building@cupertino.org PEMIT #B -b261:1 -
CUPERTINO
hl NEW CONSTRUCTION I—I ADDITION I—I ALTERATION I—I T.I. MEP F] RE -ROOF ❑ SWIMMING POOL/SPA
PROJECT ADDRESS
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OWNER r- PHONE
E-MAIL
STREET AbDR69
CITY, S ATE, ZIP
CONTRACTOR NAME ER -BUILDER COMPANY NAME
LICENSE NUMBER
LICENSE TYPE
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02
STRtET ADDRESS' I
Z-1 q J )6"(Fe
TATE, ZIP
E- ARI
I PHONE
BUS. LIC #
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❑ ARCHITECT [IOW ❑ OWNER1e4_
AGENT CO CIORAGENT❑ ENGINEER Ll ElfVELOPER ❑ TENANT
CONTACT NAME
EMAIL
STREETADDRESS
CITY STATE, ZIP PHONE
DECRII'TON
i
NGLE-FAMILY/DUPLEX ❑ MULTI -FAMILY ❑ INDUSTRIAL ❑ COMMERCIAL
USE
TYPE
OCC
SQ.FT.
VALUATION ($)
'EXISTING USE
I EXISTING SF
NEW FLOOR SF
I PORCH
SF DECK SF
DEMO SF
STORIES #
TOTAL NET SF
REMODEL
REMODEL KITCHEN
REMODELOTHR
GARAGE ❑ ATTACHED
BATHROOM SF
SF
SF SF
❑ DETACHED
EXLSING ❑ YES
EICHLER ❑ YES
SECOND STORY ADDITION ❑ YES
FIRE SPRINKLERS ❑ NO
❑ NO
❑ NO
DWELLING []YES ❑ATTACHED❑DETACHED OTHER
ISECONDDWELLING
UNITS # UNIT ADDITON: ❑ NO S F
POOLS ❑ FIBERGLASS ❑ VINYL -LINED ❑ GUNITE ❑ PREFABRICATED
POOL - SF SPA - SF SPA ATTACHED ❑ YES ❑ NO TOTAL - SF
LVED BY:
TOTAL VALUATION:
Commercial or Multi -Family Buildings with Public Swimming Pools requires Department of Environmental Heath npproval
RE -ROOF
EXISTING ROOF TYPE; E] BUILT-UP ROOF ❑ASPHALT SHINGLES❑WOOD SHAKES ❑
WOOD SHINGLES ❑TILE OTHER (SPE )
REMOVE /REPLACE ❑ NO
IF NO
I
PLYWOOD El 'h" ❑ 3/8"
PLYWOOD TYPE:
PTTCH:
ROOF CLASS
I
❑ YES
# OF LAYERS
THICKNESS [:15/8- OTHER
❑ OSB ❑ CDX OTHER
:12
A
PROPOSED ROOF TYPE: ❑BUILT-UP ROOF ❑ASPHALT SHINGLES ❑ WOOD SHAKES ❑WOOD SHINGLES ❑ OTHER
*Provide a signed copy of the Cupertino's Tear -Off Policy SF #of SQUARES
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 read this application and the information I hav provided is correct. I have read the Description of Work and verify it is accurate. I agree
to comply with all applicable local ordinances state la lating to bui struction. I authorize representatives of Cupertino to
enter the above -identified property for inspec ' purpos I cknowled orize all information contained on this application form
to be made available for public reco
Signature of Applicant/Agent: Date:
SUPPLEMENTAL INFORMATION REQUIRED
*New SFD/Second Dwelling Units/Multifamily Dwellings: A Demolition permit is required prior to issuance of a building permit for all new construction.
*Commercial Buildings: Provide a completed Hazardous Materials Disclosure form if any Hazardous Materials are being used as part of this project.
*Copy of Planning Approval Letter or Meeting with Planning prior to submittal of Building Permit application.
*HOA -Provide a letter of approval from the Home Owner's Association
BldgApp_2017.doc revised 08101117