11020031CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 19935 PRICE AVE
OWNER'S NAME: SENIOR HOUSING SOLUTIONS INC
ER'S PHONE: 4084160271
LICENSED CONTRACTOR'S DECLARATION
License Class 3 Lic. # 56"06 Ll 9
Contractor j!o ZI Date — —
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.
I hereby affirm under penalty of perjury one of the following two declarations:
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.
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.
APPLICANT CERTIFICATION -;tL .
I certify that I have read this application and state that the above in 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
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
costs, and expenses which may accrue against said City in consequence of the
granting of this permit. Additionally, the applicant understands and will comply
with all non -point source regulations per the Cupertino Municipal Code, Section
9.18.
Signature Date
OWNER -BUILDER DECLARATION
CONTRACTOR: F.D. OUELLETTE & SONSI PERMIT NO: 11020031 I
INC
[ hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons:
[, 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)
1, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec.7044, Business & Professions Code).
2767 AIELLO DR
DATE ISSUED: 02/08/2011
SAN JOSE, CA 95111 I PHONE NO: (408) 226-9400
BUILDING PERMIT INFO: BLDG ELECT r— PLUMB
MECH I— RESIDENTIAL F COMMERCIAL F
JOB DESCRIPTION: RE -STUCCO EXISTING SFDWL (1 IOOSQFT)
REVEIWED PLOT PLANS BY &SCHROEDER
I hereby affirm under penalty of perjury one of the following three
declarations:
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.
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.
I certify that in the performance of the work for which this permit is issued, I shall
not employ any person in any manner so as to become subject to the Worker's
Compensation laws of California. If, after making this certificate of exemption, I
become subject to the Worker's Compensation provisions of the Labor Code, I must
forthwith comply with such provisions or this permit shall be deemed revoked.
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 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
.mnify and keep harmless the City of Cupertino against liabilities, judgments,
.,ts, and expenses which may accrue against said City in consequence of the
granting of this permit. Additionally, the applicant understands and will comply
with all non -point source regulations per the Cupertino Municipal Code, Section
9.18.
Signature Date
Sq. Ft Floor Area: I Valuation: $22000
APN Number: 36905035.00 I Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
_ 7 ` Date:
Issued by: 7
RE -ROOFS:
All roofs shall be inspected prior to any roofing material being installed. If a roof is
installed without first obtaining an inspection, I agree to remove all new materials for
inspection.
Signature of Applicant:
Date:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
HAZARDOUS MATERIALS DISCLOSURE
I have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain
compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health &
Safety Code, Section 25532(x) should I store or handle hazardous material.
Additionally, should I use equipment or devices which emit hazardous air
contaminants as defined by the Bay Area Air Quality Management District I will
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
Health & Safety Code, Sections 25505, 25533, and 25534.
Ownpr or author' a gent:
��_� Date•
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of work's
for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name —
Lender's Address
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Licensed Professional
3 ITEMS OF 3
CITY OF CUPERTINO
PERMIT RECEIPT
Sec: Twp: Rng: Sub: Blk: Lot:
APN ........: 36905035.00
DATE ISSUED.......: 02/08/2011
RECEIPT #......... BS000012668
REFERENCE ID # 11020031
SITE ADDRESS 19935 PRICE AVE
SUBDIVISION ......
CITY CUPERTINO
IMPACT AREA ......
OPERATOR: patg
COPY # : 1
OWNER ............:
SENIOR HOUSING SOLUTIONS INC
ADDRESS
19935 PRICE AVE
CITY/STATE/ZIP ...: CUPERTINO, CA 95014-3338
RECEIVED FROM ....: OUELLETTE & SONS,IN
CONTRACTOR
.......: MITCHELL OUELLETTE LIC #
31967
COMPANY ..........:
F.D. OUELLETTE & SONS INC
ADDRESS ..........:
2767 AIELLO DR
CITY/STATE/ZIP
...: SAN JOSE, CA 95111
TELEPHONE
........: (408) 226-9400
FEE ID
UNIT
QUANTITY AMOUNT PD -TO -DT THIS REC
--------
NEW BAL
----------
1BCBSC
-------------
VALUATION
--------------------
22,000.00 1.00 0.00
1.00
0.00
0.00
1BSEISMICR
VALUATION
22,000.00 2.20 0.00
2.20
1STUCOAPP
SQ FEET
1,100.00 507.00 0.00 ----507_00
----------
------0_00
TOTAL PERMIT
----------
510.20 0.00
510.20
0.00
METHOD OF
PAYMENT
AMOUNT REFERENCE NUMBER
-------
-----------------
CHECK
---------------
---------------
510.20 #0016415
TOTAL RECEIPT
510.20
CUPERTINO
CONTRACTOR / SUBCONTRACTOR LIST
Building Department
City Of Cupertino
10300 Torre Avenue
Cupertino, CA 95014-3255
Telephone: 408-777-3228
Fax: 408-777-3333
JOB ADDRESS: I qci��^2
c-
PERMIT # L-_
OWNER'S NAME:.` �_,
4
PHONE #`t� C...
GENERAL CONTRACTOR: i- j�
�i� t_((�^ t /_-�>
BUSINESS LICENSE #
ADDRESS:
CITY/ZIPCODE:
*Our municipal code requires all businesses working in the city to have a City of Cupertino business license.
NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE
GENERAL CONTRACTOR AND ALL SUBCONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO
RUSINESS LIC ENSF._
I am not using any subcontractors: T
Signature
Please check applicable subcontractors and complete the following information:
Date
V
SUBCONTRACTOR
BUSINESS NAME
BUSINESS LICENSE #
Cabinets & Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring / Carpeting
Linoleum / Wood
Glass / Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Painting / Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner / Contractor Signature
Date
CITY OF
CUPERTINO
1 1 0 2—
c ( PLOP PLANS
C HECY6W- BX
CITY OF CUPERTINO DATE 2 s 1)
GENERAL BUILDING
PLANNING DEPT,
PERMIT APPLICATION FORM
DATE
APN # �
Date: � C l7t ny:.. DFr*r.
r
Building Address:
16?93fi— Pi2 it -c-
Mailing Address (if different from building address):
Are Hazardous Materials being used as part of th' project? Yes ElNo
HOA: (Exterior work only) Yes F-1No If
yes, provide letter from HOA
If Residential is housp ichler? Yes ❑ No
If es, needs planning approval.
Owner's Name:
Phone #: / l -- C- a'?
<1,
Contractor:
Phone::
# j�``( it j 1 lZ=
Fax:
Contractor License #: c; ; c,- ; cr L(
Cupertino Business License #:
Contact: f, l
I'D ? Lt C L-' �.c_�', 1 E': � _ -
Phone:
Fax/e-mail:
Residential Commercial ❑
Job Description:
V�o
Building Permit Info:
Bldg L3Elect ❑
Plumb ❑ Mech ❑
Type of Construction (Usage Class):
Occupancy Type:
V
1-A 1-B II/III/V-A F1 II/III B, IV -HT, V -B 0--'
Valuation: ,-•,
Square Footage:
Project Size: Counter [;--Ex ress ❑ Standard
❑ Lar e ❑ Major ❑
Green Building: Please complete relevant portion of the Green Building/LEED Checklist & attach it
to the application or if applicable, include in plan set & the sheet index.
Points Achieved:
For help, contact Build it Green at www.builditgreen.org _.
Revised 12/06/10