12080058 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 1641 POPPY NAY CON 1'RAC`fOR:DELGADO PERMITNO: 12080058
CONSTRUCTION,INC.
O\VNER'S NAME: YOSIiIKAWA SAM M TRUSTL'E 667 N FIRST ST DATE ISSUED:08/072012
OW'NEIVI'DONE; 6503363542 SAN JOSE,CA 95112 PHONE NO:(408)998-8200
1
LICENSED CO 1'RAC'OR'S DECLARATION •1013 DI?SCRIPPION: RESID61VfIAL. COMM ERCIA 1.11
License Class Liv.9 ��� T � REMODEL KITCHEN 82 SQ FT, BATH 74 SQ FT
Contractor Date g
I hereby affirmdhat I am li nsc&under the provisions of Chapter 9
(commdncin`g with Section 7000)of Division 3 of the Business&Professions
Code:rad that nn•license is in full farce and effect.
I hereby affirm under penalty of perjury one of the following(no declarations:
I have and will maintain a cenificate 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. Sq.Ft Floor Arca: Valuation:$30000
I have and will maintain Worker's Compensation Insurance,as provided for by
Section 3700 of the Labor Code,for die performance of the work for which this
\I'N Number:36615038.00 OccupancyType:
permit is issued.
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is PERMIT EXPILIES IF WORK IS NOT STARTED
correct. l agree to comply with all city and county ordinances and state laws relating WITHIN I8 SOF PERMIT ISSUANCE OR
to building construction,and hereby authorize representatives of this city to enter
Upon the above mentioned property for inspection purposes. (We)agree to save 180 DAYS F LAST CALLED INSPECTION.
indemnify and keep harmless the City of Cupertino against Iiabilkies,judgmcnis,
costs,and expenses which may accrue against said City in consequence of the L r �Q�
granting of this permit. Additionally,the applicant understands mid will comply Issued by: Date: 6
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18.
Q/ / ( L RE-ROOFS:
Signature (ice Date 111111 !!! All roofs shall be inspected prior to any roofing material being installed.If a roof is
installed without first obtaining an inspection,1 agree to remove all nese materials for
inspection.
❑ OWNER-BtIlt DEJIt DECLARATION
hereby affirm that I an,exempt from(lie Contractor's License Law formic of Signature of Applicant. Date:
the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"012 BETTER
1,as owner of the property,or my employees with wages as their sole compensation,
will do the work,and the structure is not intended or offered for sale(Sec.7044,
Business&Professions Code)
I,as owner of the property.am exclusively contracting with licensed contractors to IL\%ARDOUS MATERL\LS DISCLOSURE;
construct the project(Sec.7044,Business&Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the
California Ilealth&Safety Code,Sections 25505,25533,and 25534. 1 will
hereby affirm under penalty of perjury one of the following three maintain compliance with(lie Cupertino Municipal Code,Chapter 9.12 and the
declarations: I Iea1(h&Safcty Code.Section 25532(x)should 1 store or handle hazardous
I have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally,should 1 use equipment or devices which emit hazardous
Compensation,as provided for by Section 3700 of the Labor Code,for the air contaminants its defined by the Bay Area Air Quality Management District 1
performance of the work for which this permit is issued. will maintain compliance with the Cupertyu Municipal Code,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Ilealth&Safety Code,Sections 25505.25533,and 25534. /1
Section 3700 of the Labor Code,for the performance of the work for which this --- 1
permit is issued Owner or authorized aget� Date:
1 certify that in the performance ol'the work for which this permit is issued,I shall
not employ any person many manner so as to become subject to the Worker's
Compensation laws of California. If,after making this certificate of exemption,1 CONSTRUCTION LENDING AGENCY
become subject to the Worker's Compensation provisions of the Labor Code,I must I hereby affirm that there is a construction lending agency for the performance of
forthwith comply with such provisions or this permit shall be deemed revoked w'ork's for which this permit is issued(Sec.3097,Cir C.)
Lender's Name
A I'1'LIC\NI'CF,RTI FICATION Lender's Address
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 and state laws relating
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes.(We)agree to save ARCIII'IfFCI"S DECLARATION
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may avenue against said City in consequence of the 1 understand my plans shall be used as public records.
granting of this permit.Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section Licensed Professional
9.18.
Signature Date
CONSTRUCTION PERMIT APPLICATION �(
COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION 0D
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 t,qo
CUPERTINO (408) 777-3228 • FAX (408) 777-3333 • buildingPcupertino.org 1
El NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION/TI ❑ REVISION/DEFERRED ORIGINAL PEPNIITN
PROJECTADDRESS '/ �O APN4 15 039
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OWNER NAPC PH�NE�o-33C-�Sy S(AArYr•L('� V"•\. I•�
STREET ADORES S � / /J W 1 CI Y. STATE ZI)�, r , — 6 ot� FAX
CONTACT NAMp _ Q(� /.1 O PHONE Tromp .�•r T E-MAIL
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STREET ADDRESS CITY STATE- Zt� FAX
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❑OWNER ❑ OWNER—BUILDER ❑ OWNERAGLWT p coxrnAcrOR ❑CONTRACTOR AGENT ❑ ARCHn-Ecr ❑ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRA OR NAME /I n LICE E Ng44BOR ` LICENSE, E BUS.LIC A
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COMPANY. ME ' C��• O.� E-MAIL FAX
STREET ADORES / ��. CITY.STATEE PH�O•N h
ARCHITECT/ENGrNEER NAME / LICENSE NUMBER BUS.LIC A
COMPANY NAME / E-MAIL / FAX
Z
STREET ADDRESS/ Y.STATE,ZIP PHONE
DESCRJPT10(J�FWORKd
G�...t� -�er p..'�T—> F•rTf4---�t«c� d `�p/I d�•s •��' A �/
Ste. .-
EY TLNG USE P POSEDVSE CONSTR.TYPE nSTORIES
Sl .0 5 J G/ g Z USE TYPE OCC. SQ.FT. VALUATION(5)
=G \ S A FEW L00 A� S` TOTAL
NErAREA I�
BATHROOMw. K CHEN OTHER
REMODEL AREA - � RFAIODN AREA a. REV100EL eVlEA I
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PORCH AREA DECK AREA TOTAL DECKIPORCH AREA GARAGEAREA: LIDETACH
cle {y r-> ❑ATTACH
Y DWELLING UNITS: ISASECONDUNIT ❑YES SECONDS-TORY ❑
1 BEINGADDED• QNO ADDITION? NO
PRE.APPLICATION ❑YES n'YES.PROVMECOPYOF TSTIIEBLDCAN OYES RECEIVED BY: - j TOTAL VALUATION:
PLANNING APPLA ONO PLANNING APPROVAL LETTER EICHLERHOME' ONO y
By my signature below,1 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 1 have provided is correct. 1 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 buildiul conswetion. lout ToLr'ze/*�pressee/natives of Cupertino to enter the above-id ntified try for inspection purposes.
Signature ofApplicam/Agent: � (/^Y�-.� Date:_ �� Z
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SUPPLEMEN'IKAL�INFORNIATION REQLLIRED PLAN CHECK TYPE ROUTING SLIP
New SFD or Multifamily dwellings: Apply for demolition permit for OVER.THK COUN'ITR - '❑ BUILDING PLAN REVIEW
existing building(s). Demolition permit is required prior to issuance of building -
permit for new building. ❑ E\PRESS ❑ PLANNING PLAIN REVIEW
_Commercial Bldgs: Provide a completed Hazardous Materials Disclosure El STANDARD ElPUBLICWORss
To—ma if any Hazardous Materials are being used as part Of this project
❑' LARGE El FIRE DEPT
_Copy of Planning Approval Letter or Meeting with Planning prior to O-MAJOR - El SANITARY SEWER'DIST RICT
submittal of Building Permit application. -
❑ FXVTRONatENTALHEAtax.
B[dgApp_2011.doe revised 06/2//11
RESIDENTIAL PROJECT COVER SHEET
CAMMUMTY DEVELO
BUILDING DMSI1
Assessor's Parcel Number: APPR
Name of owner. 1 +�`7 This set of plans and specif
�} Job site during constructioi
Project address. , �� `�.0,� �� changes or alteration:
ee � ( therefrom,without approv
Contact person. &-,r ` ' S `� Phone. D S S� The stamping its plan a
be held to 9 -it or to be
Fax. q of any P ns of any
r I
Net square footage of lot. �S 3 �p BY
fv�7 v DATE
Existing Pro used \` PERMIT NO.
Square footage: First floor: �-� T i 0-73 TY n
Second floor.
Garage: c ��Cucia
TOTAL: Z
Are there at least two 10 foot by 20 foot clear spaces inside the garage? 0
Is privacy protection planting required for the project? Y V
Build it Green Total Points O
-! UPERTIP!
On what floor(s) is work being done?
7 1 5 Building Department
Brief description of work. " 4 Flat
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A U I Gull
coos
CC1Mp�lAN��
Code editions: 2eO5-CB- (Y -N)?8@9-EF-E (Y - N)26A WE
onm (-Pr (y _ 20gZ,�� (y _ NO
Reviewed BY'
Effective 1/l/08
][•�C J�'.�v�uJ
AUG 0 7 2012
BY:_-----
° ' Plan Review Process Work Book Page-8-Revised 8/05/08
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