B-2017-1735 •
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2017-1735 •
10511 CASTINE AVE CUPERTINO,CA 95014-1310(326 44 038) OWNER BUILDER
OWNER'S NAME: Roy Tapas KAnd Palit Madhumanti DATE ISSUED:10/10/2017
OWNER'S PHONE:650-224-5529 PHONE NO:
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class Lic.#
Contractor OWNER BUILDER Date 7X 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:
BATHROOM REMODEL MASTER-(96 SF);2ND BATH-(58 SF);
I hereby affirm under penalty of perjury one of the following two declarations: REMODELED OTHER(74 SF)
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.
2. 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:$35000.00
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 32644 038
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.
Signature Date Issued by:AbbyAyende
Date: 10/10/2017
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 roofmg material being installed.If a roof is
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) •
‘,A?2. 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:
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. I 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 Municipal Code,Chapter 9.12 and
exemption,I become subject to the Worker's Compensation provisions of the i the Health&Safety Code,Sections 25505,25533,and 25534.
Labor Code,I must forthwith comply with such provisions or this permit shallI l j�
be deemed revoked I OwrSer or authorized agent: GUAi /iti 1CUA
APPLICANT CERTIFICATION j Date, l o/)Orad)1-
I certify that I have read this application and state that the above information is 1 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 i 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 I understand my plans shall be used'as public records.
Sigitfture Rel ��0 e 17' Dat"U )O ab ler Licensed
Professional
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT •• BUILDING DIVISION
.(6,
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
. s (408) 777-3228 • buildingIcupertino.org PEMIT#B-
7o 1 - '73S
CUPERTINO REV# DEF#
❑ NEW CONSTRUCTION ❑ADDITION iALTERATION ❑T.I: ❑MEP ❑RE-ROOF ❑SWIMMING POOL/SPA
PROJECT ADDRESS i 0511 6 Agl"I t i A ,v.E NI UE,
C, n Q APN(I // n 14 430 30
OWNER NAME ` �0y PHONE 6S 0 9-2 t S12-1 E-MAIL a� o1VI
m��,
STREET ADDRESS ` �pp"" ( ,/ CITY, STATE,ZIP
4l
10E i N 4.1-e,wr►i kit . • L N-P .F^4, 0130 t q
IB CONTRACTOR NAME ❑OWNER-BUILDER COMPANY NAME LICENSE NUMBER LICENSE TYPE
4141 �lacANL M1OCA iv V CoNgitti Tiot�l &L5.5O
ISTREET ADDRESS CITY,STATE, ZIP I
E-MAILyv PHONEsig BUS.LIC
it
ARCHITECT yOWNER ❑OWNER AGENT 0 CONTRACTOR AGENT 0 ENGINEER 0 DEVELOPER 0 TENANT
CONTACT NAME��U.
�� n E-MAIL S.
_ ,cQ p f xeQ i r�.Jl.osd L..$Yi
Nth
STREET ADDRESS (} CITY,STATE,ZIP I vv c71�1l�P�HONE
42147 Erket Ave,41 e.. , ,fzc#Gio Ci r c-1 ei 16 61 5-(0Il ig 16 2 4-
DECRIPTO�N
�GPi mom et 9, gitisithgcrn a41--�/�' 80 vra-z)ert, cokd. Goca k-ivy ao c 4
, % 111oI-er c c e/-ot-It.. kc t /
1"_ c--ea a r .
DIGLE-FAMILY/DUPLEX 0 MULTI-FAMILY 0 INDUSTRIAL 0 COMMERCIAL I
I
EXISTING USE EXISTING SF NEW FLOOR SF PORIFH SF DECK SF DEMO SF STORIES P TOTAL NET SF USE TYPE OCC SQ.FT. VALUATION(5)
REMODEL REMODEL KITCHEN REMODELOTHR GARAGE 0 ATTACHED
BATHROOM SF, 15-4 SF SF '44. SF 0 DETACHED
•
EXISING 0 YES EICHLER 0 YES SECOND STORY ADDITION OYES
FIRE SPRINKLERS le..V0 /...NO DZf'YJO
DWELLING SECOND DWELLING ❑YES 0 ATTACHED❑DETACHED OTHER
UNITS# UNIT ADDITON: ❑NO S F
'POOLS, ❑FIBERGLASS ❑VINYL-LINED 0 GUNITE 0 PREFABRICATED
POOL-SF SPA-SF I SPA ATTACHED❑YES 0 NO I TOTAL-SF
R IVED BY: TOTAL VALUATION:
Commercial or Multi-Family Buildings with Public Swimming Pools requires Department°I-Environmental Heath approval A+ ,q.c DO• 6t)
RE-ROOFI EXISTING ROOF TYPE: Q BUILT-UP ROOF❑ASPHALT SHINGLES❑WOOD SHAKES❑WOOD SHINGL S❑TILE OTHER(SPECIFY)9
REMOVE/REPLACED NO i.IF NO PLYWOOD El 1/2- ❑3/8" PLYWOOD TYPE: PITCH: ROOF CLASS
OYES I'AOFLAYERS THICKNESS❑5/8" OTHER ❑OSB ❑CDX OTHER :12 A
PROPOSED ROOF TYPE:❑BUILT;UP ROOF EASPHALT SHINGLES 0 WOOD SHAKES❑WOOD SHINGLES 0 OTHER
*Provide a signed copy of:the Cupertino's Tear-Off Policy SF Pot 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 a state laws relati.g to building construction. I authorize representatives of Cupertino to
enter the above-identified property for inspection •urpose owledge and authorize all information contained on this application form
to be made available for public record. i /i `r D/
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 08/01/17
OWNER-BUILDER DISCLOSURE FORM •
111 COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
ep4. 10300 TORRE AVENUE•CUPERTINO,CA 95014-3255
CUPERTINO (408)777-3228• FAX(408)777-3333•buildinci cupertino.orq
Dear Property Owner(s):
An application for a building permit has been submitted in your name listing yourself as the builder of the property
improvements specified at:
SITE ADDRESS APN �� / �f BP# D_ „/4-00-
10 511 C� Alf& . `j `u
OWNER NAME OWNER ADDRESS
Ma.el ALL Meinii 1'ca,ti# IO RSI 1-c.Lfl'7Ade• 61t�i�'�i wo CI r
DESCRIPTION OF WORK: �(i4./-e-r COLArra 4I/VI, �il/1A,0d_L I ZI I�et `�1 'y e-i'-
We are providing you with an Owner-Builder Acknowledgment and Information Verification Form to make you aware of
your responsibilities and possible risk you may incur by having this permit issued in your name as,the Owner-Builder. We
will not issue a building permit until you have read, initialed your understanding of each provision,signed,and
returned this form to us at our official address indicated. An agent of the owner cannot execute this notice unless
you, the property owner, obtain the prior approval of the permitting authority.
OWNER'S ACKNOWLEDGMENT AND VERIFICATION OF INFORMATION
(DIRECTIONS:Please read and initial each statement below to signify you understand or verify this information.)
I '_1. I understand a frequent practice of unlicensed persons is to have the property owner obtain an"Owner-
Buil(er" building permit that erroneously implies that the property owner is providing his or her own labor and material
per anally. I, as an Owner-Builder, may be held liable and subject to serious financial risk for any injuries sustained by
an i licensed person and his or her employees while working on my property. My homeowner's insurance may not
pro pie coverage for those injuries. I am willfully acting as an Owner-Builder and am aware of the limits of my
insu E,nce coverage for injuries to workers on my property.
Mf I understand building permits are not required to be signed by property owners unless they are responsible for
the cg• struction and are not hiring a licensed Contractor to assume this responsibility.
I understand as an"Owner-Builder"I am the responsible party of record on the permit. I understand that I may
prot_ t myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her
nam:3 instead of my own.
•
4. I understand Contractors are required by law to be licensed and bonded in California and to list their license
nu !lers on permits and contracts.
1,41.e .. I understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the
total alue of my construction is at least five hundred dollars($500), including labor and materials, I may be
con •ered an"employer"under state and federal law.
H V 1. I understand if I am considered an"employer"under state and federal law, I must register with the state and
fede W i government,withhold payroll taxes, provide workers'compensation disability insurance, and contribute to
une ;,.loyment compensation for each "employee." I also understand my failure to abide by these laws may subject
me t serious financial risk.
MPI understand under California Contractors' State License Law, an Owner-Builder who builds single-family
resid tial structures cannot legally build them with the intent to offer them for sale, unless all work is performed by
licen d subcontractors and the number of structures does not exceed four within any calendar year, or all of the work
is pe ormed under contract with a licensed general building Contractor.
f . I understand as an Owner-Builder if I sell the property for which this permit is issued, I may be held liable for
any fr ancial or personal injuries sustained by any subsequent owner(s)that result from any latent construction
defects in the workmanship or materials.
OwnelBuilderFor,n 2010.doc revised 04/14/10
_,.., '.
142 9. I understand I may obtain more information regarding my obligations as an "employer"from the Internal
Rev nue Service, the United States Small Business Administration,the California Department of Benefit Payments,
and he California Division of Industrial Accidents. I also understand I may contact the California Contractors'State
Lic se Board (CSLB)at 1-800-321-CSLB (2752)or www.cslb.ca.gov for more information about licensed
con actors.
'4 '10. I am aware of and consent to an Owner-Builder building permit applied for in my name, and understand that I
am the party legally and financially responsible for proposed construction activity at the site address listed above.
i' L11. I agree.that, as the party legally and financially responsible for this proposed construction activity, I will abide
1ii
by ail applicable laws and requirements that govern Owner-Builders as well as employers.
P 2. I agree to notify.the issuer of this form immediately of any additions, deletions, or changes to any of the
information I have provided on this form. Licensed contractors are regulated by laws designed to protect the public. If:.
you contract with,someone who does not have a license,the Contractors'State License Board may be unable to
assist you with any financial loss you may sustain as a result of a complaint. Your only remedy against unlicensed
Contractors may be in civil court It is also important for you to understand that if an unlicensed Contractor or
employee of that individual or firm is injured while working on your property, you may be held liable for damages. If
you obtain a permit as Owner-Builder and wish to hire Contractors,you will,be responsible for verifying whether or not
those Contractors are properly licensed and the status of their workers' compensation insurance coverage.
CONSTRUCTION LENDING AGENCY
(DIRECTIONS:Please complete the following construction lending agency information.)
I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued
(Sec 3097 Civ.)
Lender Name: Lender Address:
Before a building permit can be issued,this form must be completed and signed by the property owner and
returned to the agency responsible for issuing the permit. Note:A copy of the property owner's driver's license,
' form notarization, or other verification acceptable to the city maybe required to be presented when the permit is issued
to verify the property owner's signature.
Property Owner's Signature: Mckfz RAJA* Date: /0/l o/acel3- •
(NOTE: The following Authorization Form is required to be completed by the property owner only when designating an
agent of the property owner to apply for a construction permit for the Owner-Builder).
AUTHORIZATION OF.AGENT TO ACT ON PROPERTY OWNER'S BEHALF
Excluding the Notice to Property Owner, the execution of which I understand is my personal responsibility, I hereby
authorize the following person(s)to act as my agent(s)to apply for, sign, and file the documents necessary to obtain an
Owner-Builder Permit for my project.
Scope of Construction Project(or Description of Work):
Project Location or Address:
Name of Authorized Agent: Tel No
Address of Authorized Agent:
I declare under penalty of perjury that I am the property owner for the address listed above and I personally filled out the
above information and certify its accuracy. Note:A copy of the property owner's driver's license, form notarization, or other
verification acceptable to the city may be required to be presented when the permit is issued to verify the property owner's
signature.
Property Owner's Signature: Date:
OwnerBuilderForm 2010.doc revised 04/14/10