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14050051 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 21350 COLUMBUS AVE CONTRACTOR:UNITED FIELD PERMIT NO: 14050051 REMODELING DBA OWNER'S NAME: SHEADE MARC R 17855 VANOWEN ST DATE ISSUED:05/07/2014 OWNER'S PHONE: 8189165238 RESEDA,CA 91335 PHONE NO:(818)402-5656 ❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL COMMERCIAL r Q REMODEL MASTER BATH 184 SQ FT TO INCLUDE M,E,P'S License Class_ Lic.# (S p 96 1'- Contractor Vnnlw Y,e / 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. Sq.Ft Floor Area: Valuation:$10000 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 APN Number:36205008.00 Occupancy Type: permit is issued. APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED correct.I agree to comply with all city and county ordinances and state laws relating WITHIN 180 F 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 FR M LAS CALLED INSPECTION. indemnify and keep harmless the City of Cupertino against liabilities,judgments, �� costs,and expenses which may accrue against said City in consequence of the A71 granting of this permit. Additionally,the applicant understands and will comply Issued by: Date: wi 14 non-po t so cc regulations per the Cupertino Municipal Code,Section 918. RE-ROOFS: Signature Date 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. 13 OWNER- LDER DECLARATION Signature of Applicant: Date: I hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER 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 contractors to HAZARDOUS MATERIALS DISCLOSURE construct the project(Sec.7044,Business&Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the California Health&Safety Code,Sections 25505,25533,and 25534. twill I hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the declarations: Health&Safety Code,Section 25532(a)should I store or handle hazardous I have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally,should I use equipment or devices which emit hazardous Compensation,as provided for by Section 3700 of the Labor Code,for the air contaminants as defined by the Bay Area Air Quality Management District I performance of the work for which this permit is issued. will maintain compl' nee with the Cupertino Municipal Code,Chapter 9.12 and I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety C Sect s 2550 ,25533,and 25534. Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agent: Date: permit is issued. 77 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 CONSTRUCTION LE ING 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. work's for which this permit is issued(Sec.3097,Civ C) Lender's Name APPLICANT CERTIFICATION 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 ARCHITECT'S DECLARATION indemnify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City in consequence of the I 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 b� COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION / 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 \� (408)777-3228• FAX(408)777-3333•building cDcugertino.org CUPERTINO ❑NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION/TI ❑ REVISION/DEFERRED ORIGINAL PERMIT# PROJECT ADDRESSaj3S 0 C-alo p b uS A v� -) APN# ��n L o/�O OWNER NAME I/ �y � PHONE . Q E-MAIL STREET ADDRESS Vl :;A CITY, STATE,ZIP C�/Y n Ar tt;no CONTACT NAME PHONE E-MAIL STREET ADDRESS CITY,STATE,ZIP FAX OWNER ❑ OWNER-BUILDER ❑ oWNERAGENT ❑ CONTRACTOR ❑CONfRACTORAGENr ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT -CONTRACTOR NAME 2;on LICENSE NUMBER LICENSE TYPE BUS.LIC# COMPANY NAME ow..t�_I /'p dd /►i^ �D E-MAIL FAX STREET ADDRESS I V S J `U o,now Yl`j C- t CITY,STATE,ZIP t n S Zd q C'� PHONE 8q ARCHITECT/ENGINEER NAME JLICENSE NUMBER C l 1 BUS.LIC# COMPANY NAME //+ E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE DESCRIPTION OF WORK EXISTING USE PROPOSED USE CONSTR TYPE 1 4 STORIES USE TYPE OCC. SQ.FT. VALUATION(S) EXISTG NEW FLOOR DEMO TOTAL AREA AREA AREA NET AREA BATHROOM KITCHEN OTHER REMODEL AREA REMODEL AREA REMODEL AREA PORCH AREA DECK AREA TOTAL DECK/PORCH AREA GARAGE AREA: DETACH ATTACH 9 DWELLING UNITS: IS A SECOND UNIT YES ,SECOND STORY [-]YES BEING ADDED? 13NO ADDITION? ANO PRE-APPLICATION ❑YES IF YES,PROVIDE COPY OF IS THE BLDG AN ❑YES a RECEI `� '' '`� TOTAL VALUATION: N. `� SM O d O PLANNING APPL# NO PLANNING APPROVAL LETTER EiCHLER HOME? NO '" ' � By my signature below,I certify to each of the following: I am the property owner or authori76dont to act on the property owner's behalf. I have read this application and the informations I have prow' ed is correct. I have read the Description of Work a6d verify it is accurate. I agree to comply with all applicable local ordinances and state laws relatin to uil i g construction. I authorize representatives of Cupertino to enter the above-identified property for inspection purposes. Signature of Applicant/Agent: Date: SUPPLEMENT TION.REQUIREDz � =_ { New SFD or Multifamily dwellings: Apply for demolition permit for OVER THE-COIJl\'TER - BUILDING P.1; R$VIEVE' a ��,�, existing building(s). Demolition permit is required prior to issuance of building4M permit for new building. YP s flrLAhPLALAnv Ew ' RE OW _Commercial Bldgs: Provide a completed.Hazardous Materials DisclosuresTnARD usLi wt�t�s� ` form if any Hazardous Materials are being used as part of this project. _ Copy of Planning Approval Letter or Meeting with Planning Prior to ; submittal of Building Permit application. ` , �� YSEw� ISTRI r NO IENN'iROIY➢4ENTAI BldgApp_2011.doc revised 06/21/11 Building Department City Of Cupertino 10300 Torre Avenue Cupertino,CA 95014-3255 Telephone: 408-777-3228 C O P E RT I N O Fax:408-777-3333 CONTRACTOR/SUBCONTRACTOR LIST JOB ADDRESS: x-)3.50 c0 oTrl b4 5 AV-�. PERMIT# OWNER'S NAME: U PHONE# GENERAL CONTRACTO : � V/ 0 Q 1 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 FINA OCCUPANCY INSPECTIONS) WILL* SCHEDULED ,UNTIL THE GENERAL CONTRACTOR AND ALL C TRAC ORS -HAVE OBTAINED ACITY OF CUPERTINO BUSINESS LICENSE. I am not using any subcontractors: S' " a Date Please check applicable subcontractors and co lete ng information 6/ 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 NT COMMUNITYBUILDING DIVISION-CUPERT EA�� NO APPROVED This set of plans and specifications MUST be kept at the job site during construction. It is unlavilul to make any changes or ait�raticrss on same, or to deviate therefrom, without appprc-ral frcrn the Buiidii g Official. The Stamping of this plan and spu ficatiV.,S SH?;J1 NOT be held to parmit or to be an approval of t;i 3u elation of ary pro isiovs of any City Ordinanco or StZ.'Le Law. a Itis 1 CATE PERMIT NO. ------------------------------ ra- ,Y Y Q UOPY ,- l� CUPERTINO 0 F? yt � ..! (ding Department U REV; llrUR CODE COMPLIANCE Reviewed By 3y T�107prouj D) �nb Sb�� a�o� 4s�1'e : Ss�tlaWd