B-2017-2148 I
CITY OF CUPERTINO BUILDING PERMIT 1
BUILDING ADDRESS: CONTRACTOR. PERMIT NO:B-2017 2148
22861 LONGDOWN RD CUPERTINO,CA 95014-2649(342 33 056) M S SERVICES INC
HAYWARD,CA 94545
OWNER'S NAME: CHADALAVADA RANGA R AND SUDHA R DATE ISSUED• 12/14/2017
OWNER'S PHONE:408-221-9085 PHONE NO:(510)887-5571
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO' I
I
License Class C-20 Lic.#1009199
Contractor M S SERVICES INC Date 11/30/2019 X BLDG _ELECT _PLUMB
X 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
REPLACE FURNACE(SAME LOCATION)
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
performance of the work for which this permit is issued.
+'`7 2. I have and will maintain Worker's Compensation Insurance,as provided for by
"-''`� Section 3700 of the Labor Code,for the perfonnance of the work for which this
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permit is issued. Sq.Ft Floor Area: Valuation:$2700.00
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 342 33 056
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 Mu,nicipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
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Signature I ,'') A 1 r� r o,,-/ Date 12/14/2017 Issued by Abby Ayende W
. �'' " Date: 12/14/2017
OWNER-BUILDER DECLARATION
I hereby affirm that I ant 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. 1,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:12/14/2017
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. I will
is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
permitHealth&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 it Q ality Managemen//District I
Worker's Compensation laws of California. If,after making this certificate of will maintain compliance with the Cupertino f ijunip ipal Code,Cha ter 9.12 and
exemption,I become subject to the Worker's Compensation provisions of the the Health&Safety Code,S ctions'25505 25533,and 25534.r-+
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Labor Code,I must forthwith comply with such provisions or this permit shall I h fel 2L--'---'
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be deemed revoked. -Qwner or authorized agent: t,(III
,, CL 1�
APPLICANT CERTIFICATION Date:12/14/2017 V
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, 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
Signature Date 12/14/2017 Professional
CONSTRUCTION PERMIT APPLICATION
I ,/ B
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
Wi 10300 TORRE AVENUE • CUPERTINO,CA 95014-3255 Zi
4y- 3:,. (408)777-3228 •• building@cupertino.Org PEMIT#B-1°4- - (.tel"1 c
CUPERTINO REV# DEF#
0 NEW CONSTRUC2246-TION ❑4 A - „,,,,
DDITION 11ALTE TION ❑T.I. ❑MEP ❑RE-ROOF El SWIMMING POOL/SPA
PROJECT ADDRESS
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OWNER NAME Ai C' ` PHONE 4 U —nom ' 10 jJ C E-MAIL u jc/\J 0,1:11 PAD
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STREET ADDRESS 'n CITY,STATE,ZIP lj ��P 95
fa CONTRACTOR NAME ❑OWNER-BUILDE COMPANY NAME
LICENSE NUMBER LICENSE TYPE
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ISTREETADDR SS CITY,STATE,ZIP
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E-MAILS N("/L� IkVCLV eVVt c )I�`pJ�/�//��._a 1' I I / �a� 6z 6
❑ARCHITECT✓t�OWNER 0 OWNER AGENT', NTRACTOR AGENT❑ENGINEER 0 DEVELOPER 0 TENANT -
CONTACT NAME
fj� /j��� J Q��/� EMAIL (JAL" t/�L I �V� JlV I (�J .
MIliit CO illA J�j� Cotk J i` PHONE jkille'kku(//�� /*STREET ADDRESS�� 1 �1A0 CITY Tv/1P°V V l/' t ( l�`�I ��j ` "`L/ �,
,ZIP
DESCRIPTON al.1 `.`l/r ✓� L 6'\\ b Li �J
Apace e,�l 9
SINGLE-FAMILY/DUPLEX 0 MULTI-FAMILY 0 INDUSTRIAL 0 COMMERCIALI
•
EXISTING USE EXISTING SF NEW FLOOR SF PORCH SF DECK SF DEMO SF STORIES# TOTAL NET SF
I USE TYPE OCC SQ.FT. VALUATION($).
REMODEL REMODEL KITCHEN REMODEL OTHR GARAGE ❑ATTACHED
BATHROOM.SF SF SF SF ❑DETACHED
EXISING 0 YES HER LF4 YES I SECOND STORY ADDITION 0 ES
EIC
FIRE SPRINKLERS 0 NO ❑ NO
O
DWELLINGI SECOND DWELLING DYES 0 ATTACHED 0 DETACHED I OTHER
UNITS# UNIT ADDITON: ❑NO S F - - -
POOLS! ❑FIBERGLASS 0 VINYL-LINED 0 GUNITE 0 PREFABRICATED
I SPA ATTACHED❑YES 0 NO I TOTAL-SF
POOL SF SPA-SF RECVED BY: /1 >
Commercial or Multi-Fancily Buildings with Public Swimming Pools requires Department of Environmental Heath nvproval (f`JpOb A (Q,NS)`eAAP- ITOVLIWALIJAION:
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RE-R0OFI EXISTING ROOF TYPE:. LiBUILT-UPROOF❑ASPHALT SHINGLES WOOD SHAKES❑WOOD SHINGILES❑TILE .OTHER(SPECIFY) '
.. a /z ❑3/8" PLYWOOD TYPE: PITCH: :12 ROOF CLASS
A
REMOVE/REPLACE❑NO I IF NO PLYWOOD ❑ A
YES
#OF LAYERS THICKNESS❑5/8" OTHER El OSB 1=1CDX OTHER
PROPOSED ROOF TYPE:(]BUILT-UP ROOF ❑ASPHALT SHINGLES 0 WOOD SHAKES❑WOOD SHINGLES 0 OTHER SF #of SQUARES
*Provide a signed copy of the Cupertino's Tear-Off Policy
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 inL
• tion .ur•oses./ acknowledge and authorize all information co7'/
aired o this application form
to be made available for public record. / ( / Date: I Li /7
Signature of Applicant/Agent: /�_LJ_
AW
SUPPLEMENTAL INFORMATION REQUIRED
*New SFD/Second Dwelling Units/Multifamily Dwellings:A Demolition permitis 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
BldgApp_2017.doc revised 08/01/17