B-2016-1931 CITY OF l UPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2016-1931
10221 BONNY DR CUPERTINO,CA 95014-2903(359 12 033) HOMEOWNER/BUILD
ER
OWNER'S NAME: PASSANHAPRAKASHGEORGE AND SMI HAPRAKASH DATE ISSUED:05/11/2016
OWNER'S PHONE:408-772-7884 PHONE NO:
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class Lic.#
Contractor HOMEOWNER/BUILDER Date X BLDG X 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:
TEMPORARY POWER POLE(100 AMP)
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-ins ire 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. I have and will maintain Worker's Compensation Insuranc ,as provided for by
Section 3700 of the Labor Code,for the performance of th work for which this
permit is issued. Sq.Ft Floor Area: Valuation:$250.00
APPLICANT CERTIFICATION
I certify that I have read this application and state that the abov
information is correct.I agree to comply with all city and county ordinances Number: Occupancy Type:
359 12 033
and state laws relating to building construction,and hereby aut orize 359
representatives of this city to enter upon the above mentioned roperty for
inspection purposes. (We)agree to save indemnify and keep armless the
City of Cupertino against liabilities,judgments,costs,and expe ises which PERMIT EXPIRES IF WORK IS NOT STARTED
may accrue against said City in consequence of the granting oi this permit. WITHIN 180 DAYS OF PERMIT ISSUANCE OR
Additionally,the applicant understands and will comply with all on-point
source regulations per the Cupertino Municipal Code,Section .18. 180 DAYS FROM LAST CALLED INSPECTION.
Signature Date 5/1 /2016 Issued by:Abby Ayende
Date:05/11/2016 Q!�M �jwj_,L
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
t. 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.
U4./ sale(Sec.7044,Business&Professions Code)
U_ I,as owner of the property,am exclusively contracting with licensed Signature of Applicant:
contractors to construct the project(See.7044,Business&Professions Code). Date:5/11/2016
I hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
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 Lab or 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
1 I certify that in the performance of the work for which thispermit is issued,I Health&Safety Code,Section 25532(a)should I store or handle hazardous
material. Additionally,should I use equipment or devices which emit hazardous
shall not employ any person in any manner so as to becorsle subject to the air contaminants as defined by the Bay Area Air Quality Management District I
Worker's Compensation laws of California. If,after maki lig this certificate of will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and
exemption,I become subject to the Worker's Compensatioln provisions of the the Health&Safety C ,Secti 25505, 33 and 25534.
Labor Code,I must forthwith comply with such provision or this permit shall
be deemed revoked. Owner or authorized age t•
APPLICANT CERTIFICATION Date:5/11/2016
I certify that I have read this application and state that the abov 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 represe tatives 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 sail City in Lender's Address
consequence of the granting of this permit. Additionally,the ap Acant understands
and will comply with all non-point so ce regulations per the Cupertino Municipal ARCHITECT'S DECLARATION
Code,Section 18. I understand my plans shall be used as public records.
Licensed
Signature Date /2016 Professional
i
GENERAL PERIY IT APPLICATION MEP
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO,CA 95014-3255
CUPERTINO (408)777-3228•FAX(408)777-3333•building(a)cupertino.org MISC
❑PLUMBING ❑MECHANIC LECTRICAL ❑MISCELLANEOUS
PROJECT ADDRESS p �n APN#
OWNERNAME P h PAIS All A
PHONE/JfY_7y 7165Lt E-MAIL
STREET ADDRESS Ut� CITY, 1TATEQ,ZIP ` 1 q,5 O q
FAX
CONTACT NAME PHO E-MAIL(
STREET ADDRESS CITY,STATE,,ZIP ^� '/ FAX
❑OWNER ❑ OWNER-BUILDER OWNERAGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT El ARCHITECT ARCHITECT(, ❑ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME A.ICENSE NUMBER LICENSE TYPE BUS.LIC#
IrJ IM1 re.i
COMPANY NAME E-MAIL FAX
STREET ADDRESS JI 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.,DUPLEX ❑ MULTI FAMILY PROJECT INTI WH.DLAND ❑ YES PROJECT IN ❑YES IS THE BLDG AN ❑YES
BUILDING: ❑COMMERCIAL URBANINTERFACE AREA ❑ NO FLOOD ZONE ❑NO EICHLER HOME? ❑ NO
DESCRIPTION OF WORK
i
I
TOTAL VALUATION: ^ RECEIVED BY
By my signature below,I certify to each of the following: I am thelproperty owner or authorized agent to act on the property o ner's b hal£ I have read this
application and the information I have rovided' 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 ildin struction authorize representatives of Cupertino to enter the above-identified property for inspection purposes.
Signature of Applicant/Agent: q Date:
SUPPLEMENTAL INFORMATION REQUIRED
IO OVER SHE COUNTER
Q EXPRESS
3 ❑ STAND 1RD
H LARGE',
Pr ✓,�/'lei;.
MAJOR'
MEPMiscApp 201 Ldoc revised 06/21/11
OWNER-BUILDER DISCLOSURE FORM -
COMMUNITY DEVELOPM NT DEPARTMENT-BUILDING DIVISION
10300 TORRE AVENUE CUPER I INO, CA 95014-3255
CUPERTIN0 (408)777-3228-FAX(408)777-3333-buildingCaD_cupertino.org
Dear Property Owner(s):
An application for a building permit has been submitted in your name listing yourself as the builder of the property
improvements specified at:
SITE ADDRESS 022 �' �� fJ �� L APN 2)5gs 1 _C)eb1) BID
OWNERNAM5 ( OWNERADDRESS 1v 12L[ !• QVJ �L
DESCRIPTION OF WORK:
`_i 1 PB c�
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 notice unless
you, the property owner, obtain the prior approval of the permitting authority.
OWNER'S ACKNOWLEDGMENT AND VERIFICATION OF INFORMATION
(DIRECT ONS:Please read and initial each statement below to signify you understand or verify this information.)
1. I understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner-
, Ilder"building permit that erroneously implies that the property owner is providing his or her own labor and material
personally. I, 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
provide coverage for those injuries. I am wi Ifully acting as an Owner-Builder and am aware of the limits of my
6ins 72.
. nce coverage for injuries to workers n my property.
1 understand building permits are not required to be signed by property owners unless they are responsible for
7onstruction and are not hiring a licensed Contractor to assume this responsibility.
3. 1 understand as an"Owner-Builder" I am the responsible party of record on the permit. I understand that I may
otect myself from potential financial risk y hiring a licensed Contractor and having the permit filed in his or her
;74.
instead of my own.
1 understand Contractors are requir d by law to be licensed and bonded in California and to list their license
um ers on permits and contracts.
5. 1 understand if I employ or otherwiseengage any persons, other than California licensed Contractors, and the
t I value of my construction is at least fiVE,hundred dollars ($500), including labor and materials, I may be
co •dered an"employer"under state and deral law.
6. 1 understand if I am considered an ", mployer" under state and federal law, I must register with the state and
eral government,withhold payroll taxes, provide workers' compensation disability insurance, and contribute to
unemployment compensation for each"employee." I also understand my failure to abide by these laws may subject
m serious financial risk.
n7. I understand under California Contractors'State License Law, an Owner-Builder who builds single-famil9y
sidetial structures cannot legally build th m with the intent to offer them for sale, unless a#work is performed by
licensed subcontractors and the number of Istructures does not exceed four within any calendar year, or all of the work
is performed under contract with a licensed general building Contractor.
i
8. 1 understand as an Owner-Builder if I sell the property for which this permit is issued, I may be held liable for
financial or personal injuries sustained y any subsequent owner(s)that result from any latent construction
defects in the workmanship or materials.
OWneYBuildeForm 2010.doc revised 04114/10
ae
9. 1 understand I may obtain more information regarding my obligations as an"employer"from the Internal
nue Service, the United States Small Business Administration,the California Department 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-CSLBI(2752)or www.csib.ca.gov for more information about licensed
contractors.
t
10. 1 am aware of and consent to an Owner-Builder building permit applied for in my name, and understand that I
e art legally and financial) res on ible for proposed construction activity at the site address listed above.
party 9 Y Y P P P tY
11. 1 agree that, as the party legally a�d financially responsible for this proposed construction activity, I will abide
applicable laws and requirements that govern Owner-Builders as well as employers.
12. I agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the
inf ration I have provided on this form. Licensed contractors are regulated by laws designed to protect the public. If
you contract with someone who does not have a license, the Contractors' State License Board may be unable to
assist you with any financial loss you may sustain as a result of a complaint. Your only remedy against unlicensed
Contractors may be in civil court. It is 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 responsible for verifying whether or not
those Contractors are properly licensed and the status of their workers' compensation insurance coverage.
CONSTRUCTION LENDING AGENCY
(DIRECTIONS:Please complete the following construction lending agency information.)
I hereby affirm that there is a construction len ing 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 owner's driver's license,
form notarization, or other verification acceptable to thecit ay be required to be presented when the permit is issued
to verifythe property owner's si nature.
Property Owner's Signature: Date: e' f 1
---------------------------------------------------------------------------------------------------------------------------------------------
(NOTE. The following Authorization Form is required to be completed by the property owner only when designating an
agent of the property owner to apply for a construction permit for the Owner-Builder).
AUTHORIZATION OF AG NT TO ACT ON PROPERTY OWNER'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 gent(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 o Work):
Project Location or Address: I DZZ( � � 4 F I 1 M h
1 D f-i; y )_JQ (�
Name of Authorized Agent: �b`� t✓ +11 0 LZ Tel No qO'? i 21-53-77
Address of Authorized Agent: -7 Z 4-
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: copy of the property owner's driver's license, form notarization, or other
verification acceptable to the city may- require='to be resented when the permit is issued to verify the property owner's
signature.
Property Owner's Signature: r Date:
Owner Builder Fo/m1 2010.doc revised 04/14/10