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B-2016-1907 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: CONTRACTOR: PERMI NO:B-2016-1907 10592 CULBERTSON DR CUPERTINO,CA 95014-3556(375 34 034) OWNER/BUILDER OWNER'S NAME: BISWAS AMITAVA TRUSTEE&ET AL DATE I SUED:05/09/2016 OWNER'S PHONE:408-663-7323 PHONE O: LICENSED CONTR ACTOR'S DECLARATION ATION BUILDING PERMIT INFO: License Class Lic.# Contractor OWNER/BUILDER Date X_BLDG X ELECT _PLU I hereby affirm that I am licensed under the provisions of ChaX RESIDENTIAL COMMERCIAL Chapter 9(commencing _ MECH with Section 7000)of Division 3 of the Business&Professions Code and that my license is in full force and effect. JOB DESCRIPTION: I hereby affirm under penalty of perjury one of the following two declarations: INSTALL TEMPORARY POWER POLE(100 AMP) r. 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 performance of the work for which this permit is issued. 2. 1 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:$300.00 APPLICANT CERTIFICATION 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: Occupan y Type: and state laws relating to building construction,and hereby authorize 375 34 034 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 IEF WORK IS NOT STARTED may accrue against said City in consequence the granting of this permit. WITHIN 180 DAYS Oi F PERMIT ISSUANCE OR Additionally,the applicant understands and willl comply with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION. Signature Date 5/9/2016 Issued by:Alex Vallclunea Date:05/09/2016 OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for one of the :-ROOFS: following two reasons: All roofs shall be inspected prior to my roofing material being installed.If a roof is I,as owner of the property,or my employees with wages as their sole installed without first obtaining an in pection,I agree to remove all new materials for compensation,will do the work,and the structure is not intended or offered for inspection. sale(See.7044,Business&Professions Code) 1,as owner of the property,am exclusively contracting with licensed Signature of Applicant: contractors to construct the project(See.7044,Business&Professions Code). Date:5/9/2016 i hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERING TO BE CLASS"A"OR BETTER I have and will maintain a Certificate of Consent to self-insure for Worker's 'fl Compensation,as provided for by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. HAZARDOUS ATERIALS DISCLOSURE I have and will maintain Worker's Compensation Insurance,as provided for by I have read the hazardous mater(als 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 I certify that in the performance of the work for which this permit is issued,I Health&Safety Code,Section 2 532(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 us 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 theCupertino Municipal Code,Chapter 9.12 and exemption,I become subject to the Worker's Compensation provisions of the the Health&Safety Cod ,Sections 25505,25533,and 25534. Labor Code,I must forthwith comply with such provisions or this permit shall be deemed revoked; -- - '- Owne7 or autf o—riied- gent: APPLICANT CERTIFICATION Date: /5 9/2016 1 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 ARC ECTIS DECLARATION Code,Section 9.18. 1 understand my plans shall be us d as public records. -� Licensed Signature Date /5 9/2016 Professional GENERAL PERMIT APPLICATION MEP COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION '10300 TORRE AVENUE•CUPERTINO,CA 95014-3255 (408)777-3228• FAX(408)777-3333•building ftupertino.org CUPER"t`INO MISC ":2-oltp t of o ❑PLUMBING ❑MECHANICAL ELECTRICAL Q MIS ELLANEOUS PROJECT ADDRESS I U(,L Vt/.�,o ,/to APN# Y,E } o" OWNER NAME 11 M r V (� �_11^ PHONE (ft J2 E s( J 6 �' /j ( - q h'l C'�d 1 v.�is�j q STREET ADDRESS to' 9 (0 m, i„�Q�-'Co V CITY, STATE,ZIP l ( {-p FAX J lf'�.�+ KJ u7� - .i v. .. CONTACT NAME ` ` a-0 p ���W L PHONE/p F1 7 � E MAII fJ U a r tG( l k�L b t 0 5 r`FiiR ✓ir STREET ADDRESS 10 �I q(�j �V , y jb,q CITY,STATE,ZII/P I3 f y-Vj ( 14 FAl V` s i ❑ OWNER LM"OWNER.BUILDER ❑ OWNERAGENT ❑ CONTRACTOR ❑CONIRACTORAGENT ❑ ARCHILECT -ENGINEER ❑ DEVELOPER. ❑TENANT CONTRACTOR,NAME LICENSE NUMBER LICENSE TYPE BUS.LIC 9 COMPANYNAME E-MAIL FAX STREET ADDRESS CITY,STATE;ZIP PHONE ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC$ COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE USE OF -SFD of DUPLEX ❑ MULTI-FAMILY PROJECT IN WB.DLAND ❑ YES PROJECT IN ,❑l YES IS THE BLDG AN ❑ YES BUILDING: ❑COMMERCIAL URBAN INTERFACE AREA ❑ NO FLOOD ZONE L7 NO EICHLERROME? 9-5-6 DESCRIPTION OF WORK TOTAL VALUATION: 0 RECEIVED BY By my signature belo ,I certify to each of the following': I am the property owner or authorized agent to act on the propel 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 a -ee to comply with all applicable local ordinances and state laws relating to building construction. I authorize representatives of Cupertino to enter the above-identi ed property for inspection purposes. Signature of Applicant/Agent: ! .r Date: �-B SUPPLEMENTAL INFORMATION REQUIRED 4 r 1 � OVER THE COU�TER I" EXPRESS a Z� W [] STAI\DARD ,; r L 1RGE 1!lAJOR, ME Misc,4pp_2011.doc revised 06/21/11 OWNER-BUILDER DISCLOSURE FORM COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 10300 TORRE AVENUE CUPERTINO,CA 95014-3255 GUPERTIhtO (408)777-3228• FAX(408)777-3333 building cuperbno.crg — Dear Property Owner(s): An application for a building permit has been submitted in your name listing yourself as he builder of the property improvements specified at; - �1 SITE ADDRESS fG/ ._ v1 -..ti_.APN. CPA�� BP# l OWNER NAIJiE OWNER ADDRESS: ® lis V .DESCRIPTION OF WORK-- ' ' / �i.t C z....- 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 not e-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.) 1. 1 understand a frequent practice of unlicensed persons is to have the prope y owner obtain an"Owner Builder"building permit that erroneously implies that the property owner is providing his or her own labor and material personally. 1, as an Owner-Builder, may be held liable and subject to serious financial risk for any injuries sustained by an unlicensed person and his or her employees while working on my property. My homeowner's insurance may not j provide coverage for those injuries. I am willfully acting as an Owner-Builder and a n aware of the limits of my insurance coverage for injuries to workers on my property. j2. 1 understand building permits are not required to be signed by property owners unless they are responsible for the construction and are not hiring a licensed Contractor to assume this responsibi ity. . I understand as an"Owner-Builder" I am the responsible party of record on the permit. I understand that I may protect myself from potential financial risk by hiring a licensed Contractor and havi g the permit filed in his or her name instead of my own._ I 4. 1 understand Contractors are required by law to be licensed and bonded in California and to list their license numbers on permits and contracts. I 5. I understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the total value of my construction is at least five hundred dollars ($500), including labor and materials, I may be 1t considered an"employer"under state and federal law. 6. I understand if I am considered an"employer" under state and federal law, I must register with the state and federal government, withhold payroll taxes, provide workers`compensation disabili y insurance, and contribute to unemployment compensation for each"employee." I also understand my failure to abide by these laws may subject I me to serious financialrisk. I 7. 1 understand under California Contractors' State License Law, an Owner-B jilderwho builds single-family residential structures cannot legally build them with the intent to offer them for sale, unless all work is performed by licensed subcontractors and the number of structures does not exceed four within any calendar year, or all of the work is performed under contract with a licensed general building Contractor. . I understand as an Owner-Builder if I sell the property for which this permit is issued, I may be held liable for any financial or personal injuries sustained by any subsequent owner(s)that result from any latent construction defects in the workmanship or materials. Ow erBuilderForm 2010.doc revised 04/14/10 W1 ' 9, 1 understand I may obtain more information regarding my obligations as an " mployer from the Internal Revenue Service,the United States Small Business Administration, the California epartment of Benefit Payments, and the California Division of Industrial Accidents. I also understand I may contact the California Contractors' State License Board(CSLB) at 1-800-321-CSLB (2752) or www.cslb.ca.gov for more info mation about licensed contractors. 10. 1 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. 11. 1 agree that, as the party legally and financially responsible for this proposed construction activity, I will abide by all applicable laws and requirements that govern Owner-Builders as well as employers. I I 12. 1 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-law designed to protect.the..public. if . you contract with someone who does not have a license,the Contractors'State Lic nse Board may,be unable to assist you with any financial loss youlmay sustain as a.result of a complaint.--Your only remedy against unlicensed Contractors maybe in civil court. itis 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 resp nsible for verifying whether or note those Contractors are properly Licensed and the status of their workers' compensation insurance coverage. CONSTRUCTIONLENDING 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 erty 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:, ,72 ---- ----- ---- ------------------------------- ------- =----------------= ---- ----- --------------------------------------- (NOTE: The following Authorization Form is required to be completed by the property wrier.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 PROPERTYOWNER'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' license, form notarization, or other verification acceptable to the city may be required to be presented when the permit is issued to verity the property owner's signature. Property Owner's Signature: Date: Ow erBuilderForm 2010.doc revised 04/14/10 Building Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014-3255 Telephone:. 408-777-3228 C O P E RTI N O Fax: 408-777-3333 CONTRACTOR/SUBCONTRACTOR LIST JOB ADDRESS: C 2PERMIT & � c OWNERSNAME � PHONE � GENERAL CONACTR: �, TICE SE _ # ADDRESS: tO 0 ;� J> CITY/ZIPCODE: FC)f *Our municipal code requires all businesses working in the city to have a City of Ct pertino business license. NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTIONS) WILL BE SCHEDULED UNTIL THE GENERAL CONTRACTOR AND ALL SUBCONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE° I am not using any subcontractors: niSignature Date Please check applicable subcontractors and complete the following information: SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets Millwork Gement Finishing. Electrical ' Excavation Fencing Flooring/Carpeting Linoleum/'Wood _ Glass/ Glaziing Keating Insulation Landscaping; Y Lathing i� f Masonry Painting/Wallpaper Paving _ Plastering Plumbing a; a Roofing Septic Tank Sheet Metal Sheet Rock ,f Tile- Owner/Contractor Signature Date