D-2017-0016CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS:
CONTRACTOR:
PERMIT NO: D-2017-0016
18660 PRING CT CUPERTINO, CA 95014-3822 (375 25 040)
OWNER/BUILDER
OWNER'S NAME: SHANKAR FRANCIS H AND MARGARET D TRUSTEE
DATE ISSUED: 04/27/2017
OWNER'S PHONE: 408-893-1764
PHONE NO:
LICENSED CONTRACTOR'S TOR' DECLARATION
BUILDING PERMIT INFO:
License Class Lic. #
Contractor OWNER/BUILDER Date
—BLDG _ELECT _ PLUMB
I hereby affirm that I am licensed ander the provisions of Chapter 9 (commencing
MECH 3X 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:
DEMO (E) SFD & ATTACHED GARAGE (1980 SF)
I hereby affirm under penalty of perjury one of the following two declarations:
NO SWIMMING POOL
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
performance of the work for which this permit is issued.
2. I 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: $18000.00
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
375 25 040
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.
Signature Date 04-27-2017
Issued by: Kim Dunbar
Date: 04/27/2017
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 properly, 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)
i. I, as owner of the property, am exclusively contracting with licensed
Signature ofApplicam:
contractors to construct the project (Sec.7044, Business & Professions Code).
Date: 04-27-2017
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
permit is issued.
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
3. 1 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
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 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:-'
APPLICANT CERTIFICATION
Date: 04-27-2017
1 certify that I have read this application and state that the above information is
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance
correct. I agree to comply with all city and county ordinances and state laws
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
A DECLARATION
and will comply with all non-point source regulations per the Cupertino Municipal
I understand my plans shall be used as public records.
all be used a
Code, Section 9.18.
Signature Date 04-27-2017
Licensed
professional
DEMOLITION PERMIT APPLICATION
21COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
CUPERTINO (408) 777-3228 - FAX (408) 777-3333 • buiidincl(okupertino,org
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By my signature below, I certify t6 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 ofWork and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating to.bui ing cons u tion. I representatives of Cupertino to enter the above -identified, property for inspection purposes.
Signature of Applicant/Agent: Date: y19 f
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SUPPLEMENTAL INFORMATION REQUIRED PRIOR TO ISSUANCE OF DEMOLITION PB IT
Provide Job Number from Bay Area Air Quality Management District j;Mxk,.baa md.or aQ 415-749-4762.
Provide three copies of a site plan showing protection for any trees 10" in diameter or more at 3' above.grade.
Provide letter from PG&E (408-725-3325) stating all gas and electric has been disconnected.
;4 nin Dept clearance to verifybuildin is not considered an historical landmark, Allow 10 business days.
- -
-- -
- _ --
_eol trOl contractor.tractor.Provide letter of clearanceof all fromahCens d stc1
-- - - - - -
-- - -
icants h 11 call the P bl'c Works Deparuent at 408 7 77 3104 and schedule a "habitable dwelling"
1!Ap1p�il
- - - - - - - -
s
isBinadRec clable Materials form,Provide s'ned
_ - -
Q suppression / alarm system review.
Commercial Buildings Only: Provide Fire Dept clearance for fire suppr la
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Deutolpp 2016,doc revised 03129/16
OWNER -BUILDER DISCLOSURE FORM
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228 • FAX (408) 777-3333 • building(a)cupertino.oLg
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 i DDRESS� ." Cuj, ^n � �
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APN - 4-5
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OWNER NAME
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OWNER ADDRESS
(036 v,.[fei,,e
DESCRIPTION OF WORK: iEilt� 0
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
(DIRECTIONS: 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 -
Builder" 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 willfully acting as an Owner -Builder and am aware of the limits -of my
insurance coverage for injuries to workers on my property.
t2. 1 understand building permits are not required to be signed by property owners unless they are responsible for
einga Iiensedconstruction and are not hircSontractorto assume this responsibility.
i
i� �J 3. 1 understand as an "Owner -Builder" I am the responsible party of record on the er it. I understand that I may
protect myself from potential financial risk by hiring a licensedContractor and having the permit filed in his or her
name instead of my own.
�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.
A_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
considered an "employer" under state and federal law.
J6. I understand if I am considered an empler" under state and fe eral law I must register with the state and
federal 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
me to serioy financial risk.
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A 7. I understand under California Contractors' State License Law, an Owner -Builder who 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
isperformed under contract with a licensed general building Contractor.
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8. 1 understand as an O - uilder 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.
OwnerBuilderForm 2010.doc revised 04114110
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understand I may obtain more information regarding my obligations as an "em__ ployer" from the Internal
e 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-CSLB (2752) or www.cslb.ca.gov for more information about licensed
contractors.
A0. 1 am aware of and consent to an Owner -Builder building permit applied for in my name, and understand that I
.,"e 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
all applicable laws and requirements that govern Owner -Builders as well as emp_ loyers.
t�12. 1 agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the
Qfomation 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 maybe 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.
t
CONSTRUCTION LENDING 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 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:yl�
------------------------------------------------------------------------------------------------------------------------------------------
(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 AGENT 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 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:
Address of Authorized Agent:
Tel No
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'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:
OwnerBuilderFor-in 2010.docrevised,04114/10
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BUILD:1N'fj;'11,',I`zI0N - CU 'E -VINO
APPROVED
TI is set of plarvs 5,pec;
licalbors t.'.. ST to kept at the
.-,uicion. It is ur)�,i�,`,,l to make any
changes or wer-itions on or to deviate
zlpprovai from ih ,:i'ding Official.
The 4'ampinq, z ptan and spec fic.-ji (--is SHALL NOT
.)e held to Pe t i i to be an a F)p rf'' 1: , f t t4 violation
pr(OV�S:orF of arlv t Ordjrlail.c�.,Ifr State Law,
of any pr Y
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DATE
PERMIT 41 -en U-4 — ON (,8
CUPERTINO
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COMPLIANCE &
BAY ARES ENFORCEMENT
AIRQUALITY DIVISION
MANAGEMENT
D i S T A I c T
Final House Construction
4227 Shelton Creek Lane
San Bruno, CA 94066
Regulation 71, Rule 2
Acknowledgement of
Notification and
Payment of Fees
J#: 5A399
Invoice No: 3YX54
The Bay Area Air Quality Management District (BAAQMD) acknowledges receipt of your payment and
your Asbestos Removal or Demolition Plan described as: Demolition
Site address
Start Date
Completion Date
18660 Pring Ct
Cupertino, CA 95014
May 20, 2017
June 10, 2017
Removal amounts of friable ACM 0 linear feet 0 square feet 0 cubic feet
Should it become necessary to revise this plan, please do so in the spaces provided below and immediately
copy the District by fax or by mail.
REGULATION 11-2 REVISION BAAQMD J# S 9:9:
REVISION #
1
2
3
4
5
START DATE COMPLETION DATE
NOTE: This form is not intended as a verification of either the completeness of your original notification
or of its compliance with BAAQMD Regulation 11-2. If you have any questions about this
acknowledgment, please call our office at (415) 749-4762.
CUIIIIERTINO
ldui°iilldiling Il ellr artimen't
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Pacific Gas and
,Electric Company,.
WE DELIVER ENERGY."
MARCH 3R°, 2017
BEN LAN
18660 PRING CT.
CUPERTINO, CA 95014
RE: 18660 PRING CT., CUPERTINO, CA 95014
Order Number: 112128177
To whom it may concern,
The gas meter at the above referenced address has been removed and the gas service
was cut off at main on (02123117).
The electric service & meter at the above referenced address has been disconnected and
removed on (12105116).
Sincerely,
J. A
00
Justin Pigg
Project Coordinator I Pacific Gas & Electric Co
DeAnza Division 10900 N Blaney Ave. Cupertino, CA 95014
J2PY@r)ge.com IOPFice: 408,725.2165
M -F 7:OOAM -- 3;30PM
**AVAILABLE BY APPOINTMENT ONLY**
"5afety is a full time job; don't make it a part time practice"
Pacific G" and
�i�C#iG Ertlf7lfAdlfY�
CU1111EIRTINO
dei°iilldiling Ilgell artiment
FREVH.�.Wi..D FDR CODE COWI[JANCE
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Construction and Demolition Recycling Diversion
Requirements and Instructions
Covered projects, or all construction, demolition and renovation projects that are 3,000 square feet or more
are required to complete a Waste Management Plan for the City of Cupertino demonstrating that 60% of the
material generated is recycled, in compliance with ordinance CMC 16.72.050. At the conclusion of the project
a Construction Recycling Report inust be filed with the Public Works Depat•ttnent/Environmental Division
showing the tons recycled and disposed by material type. Use tonnage information from, weight tags provided
by facilities to quantify total estimated waste and percentages for materials. Weight Tags of all material
recycled and disposed must be submitted with the final report in order to receive a Final Building
Inspection,
Recology is the only debris bin service provider franchised to do business in Cupertino.
Debris from a project 3,000 square feet or more in Cupertino can be collected and
disposed by using:
Pied check all thnt apply:
T am not using a Recology debris bin, however, the project is less than 3,000 s.f., e.g. buildings, patios,
sidewalks, driveways.
El 1 will use a Recology debris bin. By Agreement with the City, Recology will prepare my required
Waste Management Plan & Recycling Report. Contact Recology: (408) 725-4020.
1 am not using a Recology debris bin. l will provide the following submittals to the City's Public
Works Department, showing that I have recycled at least 60% of all construction demolition material:
Ask for the Construction & Demolition. Recycling Packet from the Building Department unci
complete the following:
✓ Submit et Construction and Demolition Waste Management Plan with your buildingperrnif.
applieatiolt. No fee far this plan. Forms are available at the Building/Public Works Coroner° and online
at Report the tonnage recycled and disposed, by rn.aterial type.
Recycling, facilities must be selected f •onx the City's approved list of Recycling Resources.
✓ Subedit a Construction Recycling Report form. The report is required before the Building
Depar-trttertt tivillseheclttle a ftnal r'nspection, the r•eportfortn is avrtilctble (tt the Bttilcling/Public
Works Counter and ordlinG' 1V1tGSi ELtT3er'tlrlp,arPt'et3Vlr"�ltllterttlt�
Signature: ,f Date:aa
Name: (printed) � �\ LUwv
Title: N f
Phone: _ ! _
Protect Address: w c, CAA 14- lk.�''f Ig � �j _0 (DI $4
This fror►n to remain in the project's building t)� or tit r
ReNsed 3/7/12
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duuifldilingIlDe artur en't
FREVH.�.WED FDR CODE COWI[JANCE
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City of Cupertino
Public works Department
�
!
CU►ERTENOGREEH
Progrem
Environmental Programs Division
10300 Torre Ave
Cupertino, CA 95014
408 777-3354
Construction and Demolition Recycling Diversion
Requirements and Instructions
Covered projects, or all construction, demolition and renovation projects that are 3,000 square feet or more
are required to complete a Waste Management Plan for the City of Cupertino demonstrating that 60% of the
material generated is recycled, in compliance with ordinance CMC 16.72.050. At the conclusion of the project
a Construction Recycling Report inust be filed with the Public Works Depat•ttnent/Environmental Division
showing the tons recycled and disposed by material type. Use tonnage information from, weight tags provided
by facilities to quantify total estimated waste and percentages for materials. Weight Tags of all material
recycled and disposed must be submitted with the final report in order to receive a Final Building
Inspection,
Recology is the only debris bin service provider franchised to do business in Cupertino.
Debris from a project 3,000 square feet or more in Cupertino can be collected and
disposed by using:
Pied check all thnt apply:
T am not using a Recology debris bin, however, the project is less than 3,000 s.f., e.g. buildings, patios,
sidewalks, driveways.
El 1 will use a Recology debris bin. By Agreement with the City, Recology will prepare my required
Waste Management Plan & Recycling Report. Contact Recology: (408) 725-4020.
1 am not using a Recology debris bin. l will provide the following submittals to the City's Public
Works Department, showing that I have recycled at least 60% of all construction demolition material:
Ask for the Construction & Demolition. Recycling Packet from the Building Department unci
complete the following:
✓ Submit et Construction and Demolition Waste Management Plan with your buildingperrnif.
applieatiolt. No fee far this plan. Forms are available at the Building/Public Works Coroner° and online
at Report the tonnage recycled and disposed, by rn.aterial type.
Recycling, facilities must be selected f •onx the City's approved list of Recycling Resources.
✓ Subedit a Construction Recycling Report form. The report is required before the Building
Depar-trttertt tivillseheclttle a ftnal r'nspection, the r•eportfortn is avrtilctble (tt the Bttilcling/Public
Works Counter and ordlinG' 1V1tGSi ELtT3er'tlrlp,arPt'et3Vlr"�ltllterttlt�
Signature: ,f Date:aa
Name: (printed) � �\ LUwv
Title: N f
Phone: _ ! _
Protect Address: w c, CAA 14- lk.�''f Ig � �j _0 (DI $4
This fror►n to remain in the project's building t)� or tit r
ReNsed 3/7/12
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FREVH.�.WED FDR CODE COWI[JANCE
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rlaner urange
f, 434 Park Ave Service Confirmation
`s San lose, CA 95110-2614
408-963-6868 ORDER #: 93677
planet orange WORK DATE: 4/27117
BILL -TO 109798
Ban Lan
1.8660 Pring Ct
Cupertino, CA 95014-3822
Phone: 408-893-1764
Mobile: 408-893-1764
LOCATION 109798
Ban Lan
18660 Pring Ct
Cupertino, CA 95014-3822
Phone: 408-893-1764
Mobile: 408-893-1764
Time In: 4/27/17 10:53 AM
Time Out: 4/27/17 11:23 AM
Customer Signature
Customer Is unavailable to sign
Technician Signature
Rich Munoz
License #:
Purchase Order Terms Service Description Quantity
None COD Rodent Program *Initial Visit #1* 1.00
GENERAL COMMENTS / INSTRUCTIONS
Vermin service
COD - Please collect $325 from customer
*please call before arrival
Rodent Rrogram consists of 3- total service visits all within the 2 -month's. Products used,snap traps, glue boards, fill up to 6 small golf ball size holes with foam, repair up to 2
vent screen's only.**Any additional holes,vents are subject to additional charge's.Planet Orange makes all necessary efforts under this agreements scope to control a basic
infestation.If infestation is still not completely under control after expiration of this program then we HIGHLY recommend a recurring Monthly service be set up with our sales
department.
PRODUCTS APPLICATION SUMMARY
Material Lot # LPA # AX % A.I. Conc. Active Ingredient Finished Qty Undiluted Qty
Todol PUR Black Foam
Target Pests; Rodents
Material
n/a 0.0000%
Lot # EPA # A. 1. %
1.0000 n/a 1.0000 Ounce
A.I. Conc. Active Ingredient Finished Qty Undiluted Qty
Todol Pur Fill Gun Cleaner
n/a 0.0000%
1.0000 n/a 1.0000 Ounce
Target Pests: Rodents
PRODUCTS APPLIED
Material
A.I. % Finished Qty
Application Equipment
EPA #
Undiluted Qty
Application Method Lot #
Todol PUR Black Foam
0.0000% 1.0000 Ounce
Applying material with a
sprayer
Target Pests: Rodents
Comment: Sealed off with foam all access points within the structure, no
new vermin activity observed, paid by check #1346 $325.00
Todol Pur Fill Gun Cleaner 0.0000% 1.0000 Ounce
Target Pests: Rodents
Comment: Cleaned foam gun
Applying material with a
sprayer
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Bulidling e rumen
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