10050077I CITY OF CUPERTINO BUILDING PERMIT I
BUILDING ADDRESS: 10238 PASADENA AVE I CONTRACTOR: D & B LEGACY LLC PERMIT NO: 10050077
OWNER'S NAME: D & B LEGACY LLC 10164 CARMEN AVE DATE ISSUED: 09/21/2010
OWNER'S PHONE: 4084384413 CUPERTINO, CA 95014 PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION r
BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class Lic.#
MECH r RESIDENTIAL r— COMMERCIAL
Contractor
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
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
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
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons:
I, 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 ctor to ll
construct the project (Sec.7044, Business & Professions Code). 1
I hereby affirm corder penalty of perjury one of the followingAlu-e�_---,,
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-Co0,6 I must
forthwith comply with such provisions or this permit shall be deemed'reevIco
r �L
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
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 ppt. Additionally, the applicant understands and will comply
with all non-poijit o �rce regulh�ions per the Cuperti� Municipal Code, Section
9.18. r`�j `,, t \ �_' I t
:
Date
JOB DESCRIPTION: DETACHED 2ND UNIT (640�-NO GARAGE. LOT 2
*SEE NOTES*
Sq. Ft Floor Area: Valuation: $85000
APN Number: 35718021.10238.2ND I Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
Issued by-..�,...� � Tom-- Date: -
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
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(a) 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
Healthi. afety ode, Sections 25505, 25533, and?55�4.
1 &t�
Owne P, ul►or gent a - t s €
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
Building Department
CITY OF CUPERTINO
10300 TORRE AVENUE - CUPERTINO, CA 95014-3255
CUPERTINO 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:
Lot 1 10218 (main) & 10228 (2nd unit) Pasadena Ave
Lot 2 10232 (main) & 10238 (2"d unit) Pasadena Ave
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