14050125CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 21977 MCCLELLAN RD
CONTRACTOR: SGK HOME SOLUTIONS,
PERMIT NO: 14050125
INC.
OWNER'S NAME: KAWAHARA YUICHI AND ERI
3801 CHARTER PARK CT STE B
DATE ISSUED: 05/21/2014
OWNER'S PHONE: 4086664655
SAN JOSE, CA 95136
PHONE NO: (408) 264 -6964
JOB DESCRIPTION: RESIDENTIAL E] COMMERCIAL
L CENSED CONTRACTOR'S DECLARATION
REMOVE AND REPLACE 7 WINDOWS AND 3 PATIO
License Clas ic. #
DOORS TO
MEET EGRESS
Contractor Date
I hereby of irm that I am Iii ensed under the provisions of Chapter 9
(commencing with Section 00) 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
Valuation: $9000
performance of the work for which this permit is issued.
Sq. Ft Floor Area:
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: 35713007 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 DAYS OF PERMIT ISSUANCE OR
to building construction, and hereby authorize representatives of this city to enter
180 DAYS FROG LAST CALLED INSPECTION.
upon the above mentioned property for inspection purposes. (We) agree to save
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
the
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I
costs, and expenses which may accrue against said City in consequence of
Issued by: Date:? i
granting of this permit. Additionally, the applicant understands and will comply
with all non -point source regulations per the Cupertino Municipal Code, Section
918.
RE- ROOFS:
4441y
installed. If a roof is
Date
All roofs shall be inspected prior to any roofing material being
Signatu
installed without first obtaining an inspection, I agree to remove all new materials for
inspection.
❑ OWNER- ILDER DECLARATION
Signature of Applicant: Date:
I hereby affirm that I am exempt from the Contractor's License Law for one of
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
the following two reasons:
I, as owner of the property, or my employees with wages as their sole compensation,
do the work, and the structure is not intended or offered for sale (Sec.7044,
will
Business & Professions Code)
HAZARDOUS MATERIALS DISCLOSURE
I, as owner of the property, am exclusively contracting with licensed contractors to
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. I will
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:
I have and will maintain a Certificate of Consent to self - insure for Worker's
Health & Safety Code, Section 25532(a) should I store or handle hazardous
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
will maintain compliance with the upertino Municipal Code, Chapter 9.12 and
performance of the work for which this permit is issued.
I have and will maintain Worker's Compensation Insurance, as provided for by
the Health & Safety Code, 5 05 5533, and 25534.
Section 3700 of the Labor Code, for the performance of the work for which this
rSeci
Owner or authorized agen Dat JV�JQ
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
CONSTRUCTION LE ING AGENCY
Compensation laws of California. If, after making this certificate of exemption, I
I
I hereby affirm that there is a construction lending agency for the performance of
become subject to the Worker's Compensation provisions of the Labor Code, must
work's for which this permit is issued (Sec. 3097, Civ C.)
forthwith comply with such provisions or this permit shall be deemed revoked.
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,
which may accrue against said City in consequence of the
I understand my plans shall be used as public records.
costs, and expenses
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
CUPERTINO
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISIO N
10300 TORRE AVENUE • CUPERTINO, CA 95014 -3255
(408) 777 -3228 • FAX (408) 777 -3333 • buildina(a)-cugertino.orp
'l
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❑ NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION / TI ❑ REVISION / DEFERRED \ ORIGINAL PERMIT #
PROJECT ADDRESS Z465�WAPN
# lam✓
00
OWNER NAME
ki
/�
v
E-MAIL
STREET ADDRESS I Tcr4 STATE, ZIP
FAX
CONTACT NAME
PHONE
E -MAIL
STREET ADDRESS
CITY, STATE, ZIP
FAX
❑ OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑ CONTRACrORAGENT ❑ ARCHITECT
❑ ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR N
LICENSE
LI S ETS�E' `` ` �
BUS. LIC #
COMPANY NAME 19,40V I
Q�
E -MAIL
FAX
STREET ADDRESS #2
__.a OYTZOV—�� I
C
rA 0 11 (
ARCHITECT/ENGINEER NAME
LICENSE NUMBER
V
BUS. LIC #
COMPANY NAME
E -MAIL
FAX
STREET ADDRESS
CITY, STATE, ZIP
PHONE
DESCRIPTION OF WORK
EXISTING USE
PROPOSED USE CONSTR
TYPE
# STORIES
USE
TYPE
OCC.
SQ.FT.
VALUATION ($)
EXISTG
AREA
NEW FLOOR
AREA
DEMO
AREA
TOTAL
NETAREA
BATHROOM
REMODEL AREA
KITCHEN
REMODELAREA
OTHER
REMODEL AREA
PORCH AREA
DECK AREA
TOTAL DECK/PORCH AREA
GARAGE AREA: DETACH
❑ ATTACH
# DWELLING UNITS:
IS A SECOND UNrr OYES
BEING ADDED! ❑ NO
SECOND STORY ❑ YES
ADDITION! []NO
PRE- APPLICATION ❑ YES IF YES, PROVIDE COPY OF
PLANNING APPL # ❑ NO PLANNING APPROVAL LETTER
IS THE BLDG AN ❑ YES
EICHLER HOME' ❑ NO
` RECEIVED BY:
By my signature below, I certify to each of the following: I am the property owner or authorized agent act on the pro owner's behal . I have read this
application and the information I hav p ed i co ct. I have read the Description of Work and verify It Is accurate. I ee to co ply with all applicable local
ordinances and state laws relating ction. I authorize representatives of Cupertino to enter the o - ed pr rty f pection purposes.
Signature,of Applicant/Agent Date:
SUPPLEMENTAL INFORMATION PJkQUIRED
New SFD or Multifamily dwellings: Apply for demolition permit for
existing building(s). Demolition permit is required prior to issuance of building
permit for new building.
_ Commercial Bldgs: Provide a completed Hazardous Materials Disclosure
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
PLAN CHECK TYPE
ROUTING SLIP
❑ OVER- THE.COUNTER
❑ EXPRESS
0 STANDARD
0 LARGE
❑ MAJOR '
❑ BUILDING PLAN REVIEW
❑ PLANNING PLAN REVIEW
❑ PUBLIC WORKS
❑ FIRE DEPT
❑ SANITARY SEWER DISTRICT
❑ ENVIRONMENTAL HEALTH
BldgApp 20ILdoc revised 06121111
CITY OF CUPERTINO
r,T+T ToT7AX A T/11D 121TI7 iITN!"_ DlVTCT(1N
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i C i�eclt llhi b I'l„r Ciwck Plec, P e Check
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Permit t Fee f'tumb. P< mit I et::
lttrc ° itech ImP, C)ther' hlurnb Irrslt. C)fher 1, -rc f hysl >.
14ec'z. fnsv. Pc _ Plumb. Tee. I�lcx. I s ,- 1, ,e.
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NOTE: This estimate does not inctude,jees aue to otner uepartrneno (ae. rsurtatreg, ����� •• �•��, - _.. __ _ ____ _ _,
District, etc.. These fees are oasea on me preummur
FEE ITEMS (Fee Resolution 11 -053 E . 7111131
1' 1:JJJ JJ1✓ i
FEE
QTY/FEE
_____ _
MISC ITEMS
ADDRESS: 21977 McClellan rd
DATE: 05/21/2014
REVIEWED BY: Mendez
$0.00
BP #:
*VALUATION: $9,000
APN:
0.0
hrs
*PERMIT TYPE: Building Permit
PLAN CHECK TYPE: Alteration /Repair
PRIMARY
SFD or Duplex
PENTAMATION 1 GENRES
PERMIT TYPE:
USE:
WORK
remove and replace 7 windows and 3 patio doors to meet egress
Suppl. Insp. Fee: Reg. Q OT
0,0
SCOPE
_ r
i C i�eclt llhi b I'l„r Ciwck Plec, P e Check
1ec.�, r I r,
Permit t Fee f'tumb. P< mit I et::
lttrc ° itech ImP, C)ther' hlurnb Irrslt. C)fher 1, -rc f hysl >.
14ec'z. fnsv. Pc _ Plumb. Tee. I�lcx. I s ,- 1, ,e.
rZ_ o.. C—"-. Tl:ctr •.I Qnhnnl
NOTE: This estimate does not inctude,jees aue to otner uepartrneno (ae. rsurtatreg, ����� •• �•��, - _.. __ _ ____ _ _,
District, etc.. These fees are oasea on me preummur
FEE ITEMS (Fee Resolution 11 -053 E . 7111131
FEE
QTY/FEE
_____ _
MISC ITEMS
Plan Check Fee:
$0.00
10 #
$557.00
Window / Sliding Glass Door
1 WINREP Replacement
Suppl. PC Fee: (F) Reg. Q OT
0.0
hrs
$0.00
PME Plan Check:
$0.00
Permit Fee:
$0.00
Suppl. Insp. Fee: Reg. Q OT
0,0
hrs
$0.00
PME Unit Fee:
$0.00
PME Permit Fee:
$0.00
const7`action Tax.,
ridJ inistrw;vu /'c,'E:':
E)
Work Without Permit? 0 Yes (F) No
$0.00
Advanced Plannim Fee:
$0.00
Select a Non - Residential
Building or Structure
G
0
�
Travel eZ 1 ooia n(mialiort F* ,es.
Strom Motion Fee: IBSEISMICR
$0.90
Select an Administrative Item
Bld ,, Stds Commission Fee: IBCBSC
$1.00
B QzIrS
$1.90
$557.00 TOTAL FEE:'
$558.90
r\cvwcu. vriv �.
CUPERTtt` O
SMOKE / CARBON MONOXIDE ALARMS
OWNER CERTIFICATE OF COMPLIANCE
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014 -3255
(408) 777 -3228 • FAX (408) 777 -3333 • building(5cupertino.org
F LE
(SeDJ
/� _' Permit No. 16.167 S� /�
Address % l- 6. / `t # of Alarms Smoke: Carbon Monoxide:
PURPOSE
This affidavit is a self - certification for the installation of all required Smoke and Carbon Monoxide Alarms for
compliance with 2013 CRC Section R314, 2013 CBC Sections 420.6 and 907.2.11.2 where no interior access for
inspections are required.
GENERAL INFORMATION
Existing single- family and multi- family dwellings shall be provided with Smoke Alarms and Carbon
Monoxide alarms. When the valuation of additions, alterations, or repairs to existing dwelling units exceeds
$1000.00, CRC Section R314 and CBC Sections 907.2.11.5 and 420.6 require that Smoke Alarms and /or Carbon
Monoxide Alarms be installed in the following locations:
AREA
SMOKE ALARM
CO ALARM
Outside of each separate sleeping area in the immediate vicinity of the
bedroom(s)
X
X
On every level of a dwelling unit including basements
X
X
Within each sleeping room
X
Carbon Monoxide alarms are not required in dwellings which do not contain fuel- burning appliances and that
do not have an attached garage. Carbon monoxide alarms combined with smoke alarms shall comply with
CBC Section 420.6 and shall be approved by the Office of the State Fire Marshal.
Power Supply: In dwelling units with no commercial power supply, alarm(s) may be solely battery operated.
In existing dwelling units, alarms are permitted to be solely battery operated where repairs or alterations do
not result in the removal of wall and ceiling finishes or there is no access by means of attic, basement or crawl
space. Refer to CRC Section R314 and CBC Sections 907.2.11.4 and 420.6.2. An electrical permit is required for
alarms which must be connected to the building wiring.
As owner of the above - referenced property, I hereby certify that the alarm(s) referenced above has/have been
installed in accordance with the manufacturer's instructions and in compliance with the California Building
and California Residential Codes. The alarms have been tested and are operational, as of the date signed
below.
/ have read and agree to comply with the terms and conditions of this statement
Owner (or Owner Agent's) Name:
� �CLL
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V i L i —CA N� �
Si nature......0��'....-e,/ ................... ............................... ................. Date:
Contractor Name:
Signature.................................... ............................... Lic.# ....... ............................... Date:...................
Smoke and CO form.doc revised 03118114
MODIFICATION REQUEST FORM
Association Name: Park Villas Association - Ridgecrest Date:
91312012-'
Homeowner Name: Yuichi Kawahara
Address: 21977 McClellan Road, Cupertino, CA 95014
Phone Numbers:
TlPSCrintion of work nrouosed: ,
Please attach a separate sheet with a sketch orplans for the workyou are proposing.
A licensed contractor must perforYn the work.
Name:
Contractor's License niunber, phone number and proof of insurance must be provided.
IMPORTANT, please,note the following:
1. Applicant agrees & understands submission of this form alone does not fulfill all
requirements for approval. The Board may require additional information in order to make a
decision. Until ou have teceived written Board a toval the application is considered not
arm owed.
2. Applicant understands modifications or special conditions maybe placed on completion of
work at the applicant's sole expense.
3. Applicant understands all necessary permits must be pulled from the City at the applicant's
sole expense prior to the initiation of work and after Board approval has been given.
Applicant will need to call the City's Building Department to determine which permits, if
any, are necessary.
4. Applicant also understands construction of said project entails continued maintenance of
said item for the life of the item including any damage arising from installation. If the
ownership of the unit is transferred, this responsibility must be disclosed as it does transfer
to the new homeowner
o�� „
(Homeowner Signature- Onfy)
Return to Affirmative Management Services, P.O. Box 477, Campbell, CA 95009 -0477 or Fax: 408 -244 -0090
++++++++++++++++++++++++++++++++++ + + + + + + + + + + + + + + + + + + + + + + + + + + + + + ++
(For HOA Use Only)
❑ Approved i f, _ , t.J %lLt U`e. LC/ l/i yl (M �3
Approved with Contingencies: 4kv W f ,oty S /
�
, o�S r-
❑ Denied
❑ Denied as additional information is required (as highlighted):
This matter was reviewed by: 200-✓'(
J
Name:
Address:
Email:
Phone:
MANN
CHECKED BY
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1VhNTlNlG DEPT.
DATE
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Off: 408-264-6964 www.sgkhomesolutions.com Fax: 408-264-6126