B-2017-1925 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2017-1925
19020 BARNHART AVE CUPERTINO,CA 95014-3502(375 37 040) ATKINSON
CLIMATROLLERS INC
SAN JOSE,CA.95112
OWNER'S NAME: KUMAR RAMAMURTHY AND PRABHA TRUSTEE DATE ISSUED: 11/07/2017
OWNER'S PHONE:408-506-3284 PHONE NO:(408)294-6290
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class C-20 Lic.#258540
Contractor ATKINSON CLIMATROLLERS INC Date 12/31/2018 X BLDG _ELECT _PLUMB •
I hereby affirm that I am licensed under the provisions of Chapter 9(commencing MECH RESIDENTIAL_COMMERCIAL
with Section 7000)of Division 3 of the Business&Professions Code and that my
license is in full force and effect. JOB DESCRIPTION:
REPLACE FURNACE(SAME LOCATION);(N)AC UNIT
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.
VA
�� ,�"'*. 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:$12534.00
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 37 040
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.
gnature s� << =� Date 11/7/2017 Issued by:Abby Ayende
Date: 11/07/2017
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
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)
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:11/7/2017
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. 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 the Health&Safety Code,Sections 25505,25533,and 25534.
Labor Code,I must forthwith comply with such provisions or this permit shall d / /
be deemed revoked. �w liner or authorized agent: d/ G e../4":%"../
../4: .
APPLICANT CERTIFICATION Date:11/7/2017
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. I understand my plans shall be used as public records.
Signature Date 11/7/2017 Licensed
Professional
•
CONSTRUCTION PERMIT APPLICATION
\r.. . COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
4 B
10300 TORRE AVENUE • CUPERTINO CA 95014-3255 •
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(408) 777-3228 • building�:cuPertino.org PEMIT AB- � �� -
CUPERTINO REVS DEFF
❑ NEW CONSTRUCTION ❑ADDITION,'ALTERATION ❑T.I. ❑MEP ❑RE-ROOF ❑SWIMMING POOL/SPA
PROJECT AD1RESS0
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SINGLE-FAMILY/DUPLEX 0 MULTI-FAMILY 0 INDUSTRIAL 0 COMMERCIAL. I
I
ISTING USE EXISTING SF NEW FLOOR SF PORCH SF DECK SF DEMO SF STORIES a TOTAL NET SF USE TYPE OCC SQ.FT. VALUATION(5)
EMODEL REMODEL KITCHEN REMODELOTHR GARAGE ❑ATTACHEDOSINGATHROOM SF SF SF SF ❑DETACHED r7ISING ❑YES EICHLER ❑YES SECONDSTORYADDITION ❑YES
E SPRINKLERS❑NO ❑ NO ❑NO
WELLING SECOND DWELLING ❑YES ❑ATTACHED❑DETACHED OTHER
NUNITADDITON: ❑NO SF
OOLS ❑FIBERGLASS ❑VINYL-LINED ❑GUNITE 0 PREFABRICATED
'POOL-SF SPA-SF I SPA ATTACHED ID YES 0 NO 1 TOTAL-SF
BEC- D BY: O V A IpN:
Commercial or Multi-Family Buildings with Public Swimming Pools reauirec Department ofEnvironmental Heath approval I l , ' Q pl.MUL -1 L
RE-ROOF EXISTING ROOF TYPE: ❑BUILT-UP ROOF❑ASPHALT SHINGLES❑WOOD SHAKES❑WOOD SHING ES❑TIE OTHER(SPECIFY)
'REMOVE/REPLACE❑NO IF NO PLYWOOD I=1 1/2" ❑3/8" ' PLYWOOD TYPE: PITCH: ROOF CLASS
❑yes FOFLAYERS THICKNESS❑5/8" OTHER ❑OSB ❑CDX OTHER :12 A
PROPOSED ROOF TYPE:❑BUILT-UP ROOF ❑ASPHALT SHINGLES ❑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 ins•e'ctiioon purposes. I acknowledge and authorize all informationcontained on this application form
to be made available for public record. :��i /ia /1 / / V
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
1
Bldg,9pp_2017.doc revised 08/01/17'