B-2017-1625 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2017-1625
18720 NEWSOM AVE CUPERTINO,CA 95014-3855(375 30 007) RELIABLE&LOYAL
CONSTRUCTION
MANAGEMENT
CAMPBELL,CA 95008
OWNER'S NAME: KUDLAMATH SADASHIV G AND GEETA DATE ISSUED:09/20/2017
OWNER'S PHONE:408-394-9727 PHONE NO:(408)509-2602
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class B Lic.#916332
Contractor RELIABLE&LOYAL CONSTRUCTION MANAGEMENT Date X BLDG X ELECT _PLUMB
05/31/2018 _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 JOB DESCRIPTION:
license is in full force and effect. (N)TEMPORARY POWER POLE(100 AMPS)
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
.erformance of the work for which this permit is issued.
t4''I have and will maintain Worker's Compensation Insurance,as provided for by
"ter Section 3700 of the Labor Code,for the performance of the work for which this Sq.Ft Floor Area: Valuation:$450.00
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 375 30 007
' 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 WITHIN 180 DAYS OF PERMIT ISSUANCE OR
may accrue against said City in consequence of the granting of this permit.
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.
nature ( Date:09/20/2017 Date 9/20/2017 Issued by: /2017Abby ende
OWNER-BUILDER DECLARATION RE-ROOFS:
.'1 i1 hereby affirm that I am exempt from the Contractor's License Law for one of the All roofs shall be inspected prior to any roofing material being installed.If a roof is
following two reasons: installed without first obtaining an inspection,I agree to remove all new materials for
1. 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 of Applicant:
z. I,as owner of the property,am exclusively contracting with licensed Date:9/20/2017
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
will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and
Worker's Compensation laws of California. If,after making this certificate of 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 a r or authorized agent:
be deemed revoked. tsate:9/20/2017
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
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
Professional
Signature Date 9/20/2017
CONSTRUCTION PERMIT APPLICATION
•
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
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10300 TORRE AVENUE • CUPERTINO,CA 95014-3255
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(408) 777-3228 ••.building@cupertino.org PEMIT#B -
-
CUPERTINQ REV# DEF#
❑ NEW CONSTRUCTION ADDITION ❑ALTERATION ❑T.I. ❑MEP ❑RE-ROOF ❑SWIMMING POOL/SPA
PROJECT ADDRESS •
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OWNER NAME i1� Y 1 PHONE E-MAIL) �J�J+r
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STREET ADDRESS CITY, STATE,ZIP
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[CONTRACTOR NAME. 0 OWNER-BUILDER COMPANY NAME LICENSE NUMBER LICENSE TYPE
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ISTREET ADDRESS CITY,STATE, ZIP
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E-MAIL `` PHONE
0 ARCHITECT ❑OWNER ❑OWNER AGENT IR/CONTRACTOR AGENT❑ENGINEER 0 DEVELOPER 0 TENANT
CONTACT NAME E-MAIL
STREET ADDRESS' CITY,STATE,ZIP PHONE
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DECRIPTON
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NGLE-FAMILY/DUPLEX 0 MULTI-FAMILY ❑INDUSTRIAL 0 COMMERCIAL I •
EXISTING USE EXISTING SF NEW FLOOR SF PORCH SF DECK SF DEMO SF STORIES S TOTAL NET SF USE TYPE OCC SQ.FT. VALUATION($)
REMODEL REMODEL KITCHEN REMODEL OTHR GARAGE ❑ATTACHED
BATHROOM SF SF SF SF ❑DETACHED
•
EXISING ❑YES EICHLER 0 YES, SECOND STORY ADDITION D YES
NO
FIRE SPRINKLERS 0 NO 0 NO
DWELLING SECOND DWELLING ❑YES ❑ATTACHED❑DETACHED OTHER
UNITS# UNIT ADDITON: ❑NO :, : S F
POOLS! ❑FIBERGLASS 0 VINYL-LINED'❑GUNITE 0 PREFABRICATED
POOL-SF SPA-SF SPA ATTACHED❑YES 0 NO TOTAL-SF ARE IVED BY: - I a TA UATI N:
Conmercial or Multi-Family Buildings with Public Swimming Pools requires Department of Environmentaloin
Heath coval ( () /I WiP al 0
RE-ROOFS EXISTING ROOF TYPE: ❑BUILT-UP ROOF❑ASPHALT SHINGLES WOOD SHAKES❑WOOD SHINGLES❑ OTHER(SPECIFY) .
REMOVE/REPLACE❑NO IF NO PLYWOOD 1:11/2" ❑3/8" PLYWOOD TYPE: PITCH: ROOF CLASS
❑YES I S OF LAYERS THICKNESS❑5/8" OTHER 1:1OSB 1=I CDX OTHER .12 A
PROPOSED ROOF TYPE:❑BUILT-UP ROOF ❑ASPHALT SHINGLES 0 WOOD SHAKES❑WOOD SHINGLES 0 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 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. I acknowledge and authorize all information contained on this application form
to be made available for public record. ... '
Signature of Applicant/Agent:_ Date: "l f 2:b/f• '
SUPPLEMENTAL INFORMATION REQUIRED
i
*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 08/01/17
.