B-2016-1734 (2) CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2016-1734
21891 LOMITAAVE CUPERTINO,CA 95014-2829(357 16 075) ALPS CONSTRUCTION
&REMODELING INC
SAN JOSE,CA 95129
OWNER'S NAME:KUILA KAUSHIK AND MONDAL DIPANWITA DATE ISSUED:08/15/2016
OWNER'S PHONE:510-304-2370 PHONE NO;(408)441.0967
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class GENERAL BUILDING CONTRACTOR Llc.#909433
Contractor ALPS CONSTRUCTION&REMODELING INC Date 01/31/2020 X BLDG_ELECT_PLUMB
I hereby affirm that I am licensed under the provisions of Chapter 9(commencing MECH X 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:
CONSTRUCT(N)2-STORY SFD(2,701.4 S.F.);(N)ATTACHED
I hereby affirm under penalty of perjury one of the following two declarations: GARAGE(440 S.F.);(N)REAR PORCH(563 S.F.)
1. I have and will maintain a certificate of consent to self-insure for Worker's REV#2-REVISE KITCHEN&2ND FLOOR BATHROOM-MOVING
Compensation,as provided for by Section 3700 of the Labor Code,for the ONE WALL IN EACH ROOM-ISSUED 4/25/2017
performance of the work for which this permit is issued. REV#1-CHANGE PORCH STRUCTURE FROM WOOD TO
z. I have and will maintain Worker's Compensation Insurance,as provided for by CONCRETE-ISSUED 9/20/16
/1-8be1i n�370-0 of the Labor Code,for the performance of die work for which this REV#3-REVISE TREE SPECIES-LANDSCAPE-ISSUED 3/27/2018
permit is issued.
APPLICANT CERTIFICATION Sq.Ft Floor Area:3141 Valuation:$175000.00
1 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 357 16 165 Deferred Submittal(R-3),R-3(Custom),R-3(Custom),U
representatives of this city to enter upon the above mentioned property for (Private Gar/Ag Bldg),U(Private Gar/Ag Bldg)
Inspection purposes. (We)agree to save Indemnify and keep harmless the
City of Cupertino against liabilities,judgments,costs,and expenses which
may accrue against said consequence of the granting this permit. PERMIT EXPIRES IF WORK IS NOT STARTED
Additionally,the applicantt understands
rstands and will comply with all ll non-point
source regulations per the C ertin uniclpal Code,Section 9.18. WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
Signature Date 3L2712018
Issued by:Abby Ayende
OWNER-BUILDER DECLARATION Date:08/15/2016
1 hereby affirm that I am exempt from the Contractor's License Law for one of the
following two reasons: RL-ROOFS:
1. I,as owner of the property,or my employees with wages as their sole All roofs shall be inspected prior to any roofing material being installed.If a roof is
compensation,will do the work,and the structure is not intended or offered for installed without fust obtaining an inspection,I agree to remove all new materials for
sale(See.7044,Business&Professions Code) inspection.
2. I,as owner of the property,an exclusively contracting with licensed
contractors to construct the project(Sm.7044,Business&Professions Code). Signature of Applicant:
I hereby affirm under penalty of perjury one of the fo0owing three declarations: Date:3 018
1. 1 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 ALL ROOF COVERINGS'TO BE CLASS"A"OR BETTER
performance of the work for which this permit is issued.
2. I have and will maintain Worker's Compensation Insurance,as provided for by HAZARDOUS MATERIALS DISCLOSURE
Section 3700 of the Labor Code,for the performance of the work for which this I have read the hazardous materials requirements under Chapter 6.95 of the
permit is issued. California Health&Safety Code,Sections 25505,25533,and 25534.1 will
3. 1 certify that in the performance of the work for which this permit is issued,I maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
shall not employ any person in any manner so as to become subject to die Health&Safety Code,Section 25532(a)should I store or handle hazardous
Worker's Compensation laws o£Califomia.If,after making this certificate of material.Additionally,should I use equipment or devices which emit hazardous
exemption,I become subject to the Worker's Compensation provisions of the air contaminants as defined by the Bay Area Air Quality Management District I
Labor Code,I must Forthwith comply with such provisions or this permit shall will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and
be deemed revoked. the Health&Safety Code,Sections 25505, :5Z33, d 25534.
APPLICANT CERTIFICATION Owner or authorized agent:
I certify that I have read this application and state that the above Information Is Date: 2/2018
correct.I agree to comply with all city and county ordinances and state laws CONSTRUCTION LENDING AGENCY
relating to building construction,and hereby authorize representatives of this city I hereby affirm that there is a construction lending agency for the performance
to enter upon the above mentioned property for Inspection purposes. (Vde)agree of work's for which this permit is issued(Sec.3097,Civ C.)
to save indemnify and keep harmless the City of Cupertino against liabilities, Lender's Name
judgments,costs,and expenses which may accrue against said City In
consequence of the granting of this permit.Additionally,the applicant understands Lender's Address
and will comply with all non-point source regulations per the Cupertino Municipal
Code,Section 9.18. ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Signature Date 3/27/2018
Licensed
professional
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO,CA 95014-3255
[a (408)777-3228• building@cupertino.org PEMIT#B 2-01 1-1.3q
CUPERTINO REV#-' DEF#_
❑NEW CONSTRUCTION ❑ADDITION ❑ALTERATION❑T.I. ❑MEP FIRE-ROOF ❑SWIMMING POOL/SPA
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❑CONTRACTORNAME ❑OWNER-BUILDER COMPANY NAME /�` LICENSE NUMBER LICENSE TYPE
STREETADDRESS CITY'STATE'ZIP
E-MAIL PHONE BUS.LIC.#
[:3 ARCHITECT ❑OWNER❑OWNER AGENT❑CONTRACTOR AGENT El ENGINEER❑DEVELOPER❑TENANT
CONTACT NAME E-MAIL
STREET ADDRESS CITY,STATE,ZtP PHONE
DESCRIPTON B
OSINGLE-FAMILY/DUPLEX ❑MULTI-FAMILY ❑INDUSTRIAL ❑COMMERCIAL
EXISTING USE EXISTINGSF NEWFLOORSA PORCHSF DECKSP DEMO SF STORRII TOTALNETSF USE TYPE OCC '$Q.FT. VALUATION
REMODEL REMODEL Kl'I'CHEN AEAIODEL OTHR GARAGE E]ATTACHED
BATHROOM SF �SF SA SF E]DETACHED
EXISING ❑YES EICHLER ❑YEs SECONDSTORYADDITION OYES
FIRE SPRINKLERS D NO ❑NO El
DWELLING SECONDDWELLING E]YES❑ATTACHED❑DETACHED OTHER
UNITSp UNITADDDION: [JNO SF
POOLS ❑FIBERGLASS ❑VINYL-LINED❑GUNITE E]PREFABRICATED
POOL-SF SPA-SF I SPAATTACHED L1yDs ❑NO TOTAL-SE
REQ&IVED BY: TOTALVALll ON:
Can ue c'aluMulti-Fuii7u.Rui(dincs a+ifl Pu(+!'c SrY nn Poo[s�e"'i es De+n'f c t)En a W HIM nppr vrtl l(J)�tpl�/U
RE-ROOF EXISTING ROOF TYPE: ❑BUILT-UP ROOF,❑ASPHALT SHINGLES❑WOOD 51-IAKES❑WOOD SHINGLES❑TILE OTIIER(SPECIFY)
REMOVE/REPLACE❑NO IF NO PLYWOOD ❑+A.+ ❑3/8" PLYiNOOD TYPE: PITCH: .ROOF,CLASS
❑YES #OF LAYERS THICKNESS❑5/8" OTHER ❑OSB ❑CDX OTHER •12 A
PROPOSED ROOF TYPE:DBUILT-UP ROOF DASPHALT SHINGLES E1WOOD SHAKES OWOOD SIiINGLES DOTHER
*Provide a signed copy of the Cupertino's Tear-Off Policy SF noE 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 purpose. I a nowledge and authorize all information contained on this application form
to be made available for public r r I c2
Signature of Applicant/Agent t Date: a
SUPPLEMENTAL INFORMATION R QUIRED
*New SFD/Second Dwelling Units/Multifamily Dwellings:A Demolition permit is required prior to issuance of a building permit for all new construction.
*Corrnnercial 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.doe revised 08101117