10050076CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10218 PASADENA AVE
CONTRACTOR: D & B LEGACY LLC
PERMIT NO: 10050076
OWNER'S NAME:
CUPERTINO, CA 95014
PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION
r r— r
BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class Lic.#
MECH r— RESIDENTIAL r COMMERCIAL r
Contractor Date
I hereby affirm that I am licensed corder the provisions of Chapter 9
JOB DESCRIPTION: MAIN HOUSE 1,893', BASEMENT 1,445' WITH ATTACHED
(commencing with Section 7000) of Division 3 of the Business & Professions
GARAGE 424' (TOTAL 3,762').LOT 1
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
Sq. Ft Floor Area:
Valuation: $560000
Section 3700 of the Labor Code, for the performance of the work for which this
permit is issued.
APN Number: 37518021.10218
Occupancy Type:
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
PERMIT EXPIRES IF WORK IS NOT STARTED
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
costs, and expenses which may accrue against said City in consequence of the
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
granting of this permit. Additionally, the applicant understands and will comply
180 DAYS FROM LAST CALLED INSPECTION.
with all non -point source regulations per the Cupertino Municipal Code, Section
9.18.E
Issued byr - % Date, — s
Signature Date
f
❑ OWNER -BUILDER DECLARATION
RE -ROOFS:
I hereby affirm that I am exempt from the Contractor's License Law for one of
All roofs shall be inspected prior to any roofing material being installed. If a roof is
the following two reasons:
installed without first obtaining an inspection, I agree to remove all new materials for
I, as owner of the property, or my employees with wages as their sole compensation,
inspection.
will do the work, and the structure is not intended or offered for sale (Sec.7044,
Business & Professions Code) 4_
tractors
Signature of Applicant: Date:
I, as owner of the property, am exclusively contracting with licens "� fc to
construct the project (5ec.7044, Business &Professions Code).
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
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
HAZARDOUS MATERIALS DISCLOSURE
Compensation, as provided for by Section 3700 of the Labor Code, for the
I have read the hazardous materials requirements under Chapter 6.95 of the
performance of the work for which this permit is issued.
California Health & Safety Code, Sections 25505, 25533, and 25534. 1 will maintain
I have and will maintain Worker's Compensation Insurance, as provided for by
compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health &
Section 3700 of the Labor Code, for the performance of the work for which this
Safety Code, Section 25532(a) should I store or handle hazardous material.
Additionally, should I use equipment or devices which emit hazardous air
permit is issued.
contaminants as defined by the Bay Area Air Quality Management District I will
I certify that in the performance of the work for which this permit is issued, I shall
maintain �ompviance with the Cupertino Municipal Code, Chapter 9.12 and the
not employ any person in any manner so as to become subject to the Worker's
Healthy c,iSafet� Code, Sections 25505, 25533, and 2734.
Compensation laws of California. If, after making this certificate of exemptio 1
become subject to the Worker's Compensation of the Labor Codem t
Owt
Date: I
forthwith comply with such provisions or this permit shall be deemed revoked
b
APPLICANT CERTIFICATION
CONSTRUCTION LENDING AGENCY
I certify that I have read this application and state that the above information is
I hereby affirm that there is a construction lending agency for the performance of work's
correct. I agree to comply with all city and county ordinances and state laws relating
for which this permit is issued (Sec. 3097, Civ C.)
to building construction, and hereby authorize representatives of this city to enter
Lender's Name
upon the above mentioned property for inspection purposes. (We) agree to save
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
Lender's Address
costs, and expenses which may accrue against said City in consequence of the
granting of Additionally, the applicant understands and will comply
, ARCHITECTS DECLARATION
Uipet.
b
Licensed Professional
�10
CUPERTINO
Building Department
CITY OF CUPERTINO
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
TELEPHONE: (408) 777-3228 • FAX: (408) 777-3333
OFFICIAL NOTIFICATION OF ADDRESS CHANGE
TO: All Agencies
FROM: City of Cupertino
DATE: May 25, 2010
RE: Address Change APN #357-18-021
Please note the following address change: 10216 Pasadena Ave is being divided into 2 lots with a
main house and a detached 2nd unit each lot. 10216 Pasadena will_not be used. The new addresses
are as follows: P-prmtf41j)a oo'74o .'+loo500,15
Lot 1 10218 (main) & 10228 (2 unit) unit) Pasadena Ave
Lot 2 10232 (main) & 10238 (2" d unit) Pasadena Ave
arm r�� !og p®7!6 1005'rv�7
Please update your records accordingly. See attached map.
The new address will take effect 30 days from the date of this letter. If you have any questions,
please call me at (408) 777-3246.
Sincerely,
Susan Winslow
Administrative Clerk
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City of Cupertino
Basemap Labels
Abc Street Names
Primary Address Labels
Freeway
Basemap
Street Centerline
County Freeways
County Major Roads
Right -of -Way
Parcels
City Boundary
Aerials - 2006
SCALE 1 : 1,868
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FEET
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http://gissvr/cupertinointranet/home/mapFile.aspx Thursday, May 27, 2010 11:56 AM
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