B-2016-2715 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2016-2715
22478 SANTA PAULAAVE CUPERTINO,CA 95014-2757(357 05 042) LOTUS PAINTING&
GLASS INC
SUNNYVALE,CA
94086
OWNER'S NAME: SHARMARUPESHAND NIDHI DATE ISSUED:11/04/2016
OWNER'S PHONE:408-833-5489 PHONE NO:(408)926-0199
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class C-33 C-17 Lic.#553482
Contractor LOTUS PAINTING&GLASS INC Date 02/28/2018 X 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:
• REPLACE(12)WINDOWS AND(1)PATIO FRENCH DOOR
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.
21 have and will maintain Worker's Compensation Insurance,as provided for by
t IV j' Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued. Sq.Ft Floor Area: Valuation:$15000.00
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 357 05 042
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.
USignature Date 11/4/2016 Issued by:Kim Dunbar
Date: 11/04/2016
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:11/4/2016
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
be deemed revoked. /
(/
Owner or authorized agent: ----off
APPLICANT CERTIFICATION Date:11/4/2016
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.
Licensed •
Signature Date 11/4/2016 Professional
r Mcp- 2---/ l' -
\ / CONSTRUCTION
-
\ CONSTRUCTION PERMIT APPLICATION '
VCOMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255
I O (408)777-3228• FAX(408)777-3333•buildinq(@cupertino.orq
CUPERT
❑NEW CONSTRUCTION ❑ ADDITIIO�N ❑ ALTERATION/TI -❑ REVISION/DEFERRED ORIGINAL PERMIT#
PROJECT ADDRESS 4A2V78,..
/� ON(d APN# 351- ....,m, 04-2_-
OWNERNAME PHONE ; E-MAIL
STREET ADDRESS CITY,S ZIP q FAX,
CONTACT NAME ! PHONE 06? 1 / E-MAIL
1i1" 04.-11;10\.,„
STREET ADDRESS CITY,STATE,ZIP FAX
❑ OWNER 0 OWNER-BUILDER 0 OWNER AGENT 0 CONTRACTOR 0 CONTRACTOR AGENT 0 ARCHITECT ElENGINEER 0 DEVELOPER 0 TENANT
CONTRACTOR NAME AptviSly/ LICENSE NUMBER - 432_ LICENSE TYPE BUS.LIC#
COMPANY NAME /4,11/94,0,-, e, ,J �� E-MAIL �4 � � FAX
STREET ADDRESS J �� l' CITY,STATE,ZIP ��r® y� PHOh j� ^--;37/76,/'�'
ch
� t3 6J
ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC#
COMPANYNAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
DESCRIPTION OF WORKAN
P' ' // � / # ; e 0Oat-C ;,: I
EXISTING USE ' PROPOSED USE CONSTR.TYPE #STORIES
USE TYPE OCC. SQ.FT. VALUATION($)
EXISTG NEW FLOOR DEMO - TOTAL
AREA AREA AREA NET AREA
BATHROOM KITCHEN OTHER
REMODEL AREA REMODEL AREA REMODEL AREA
PORCH AREA DECK AREA TOTAL DECK/PORCH AREA GARAGE AREA: ❑DETACH
0 ATTACH
#DWELLING UNITS: IS A SECOND UNIT ❑YES SECOND STORY ❑YES -
BEING ADDED? 0 NO ADDITION? 0 NO
PRE-APPLICATION ❑YES IF YES,PROVIDE COPY OF IS THE BLDG AN ❑YES EIVED BY'" '_[ r_:i TTAL VALUATION:
PLANNING APPL# 0 N PLANNING APPROVAL LETTER EICHLER HOME? 0 N ; _ isI
` (56.0By my signature below,I certify to each of the following: I am the-property owner or authorized agent to act the property owner's behalf. I have read this
application and the information I have provided is correct. have read the Description of Work and verify it is accurate. I.gree to comply with all applicable local
ordinances and state laws relating to building co�struction 'autho -representatives of Cupertino to enter the above-id' tified,.operty for inspection purposes.
Signature of Applicant/Agent: "lit Date:
SUPPLEMENTAL INFORMATION` Q PLAN UIRED
�CIiECK:T TE ' / ._ ROUTING SLIP .- -
_New SFD or Multifamily dwellings: Apply for demolition permit for ] oV Ex-TIDE Coux rEx BUILDING PLAN REt Eci
existing building(s). Demolition permit is required prior to issuance of building
permit for new building. -0 EXPRESS 0-PLANNING PLAN REVIEW
Commercial Bldgs: Provide a completed Hazardous Materials Disclosure 0 STANDARD 0 PUBLIC WORMS
form if any Hazardous Materials are being used as part of this project. Q.LARGE: 0 FIRE DEPT,
Copy of Planning Approval Letter or Meeting with Planning prior to MAJOR 0=SANITARY SEWER DISTRICT '.
submittal of Building Permit application.
- - _ 0 ENVIRONMENTAL HEALTH
BldgApp_2011.doc revised 06/21/11