B-2016-1463 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO::B-2016-1463
10789 S BLANEY AVE CUPERTINO,CA 95014(369 34 052) AD&C DESIGN INC
FREMONT,CA 94539
OWNER'S NAME: PACIFIC RIM PARK LLC DATE ISSUED:03/03/2016
OWNER'S PHONE:408-891-8722 PHONE NO:(510)625-9566
T.ICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class C65 Lic.#929828
Contractor AD&C DESIGN INC Date 11/30/2017 X BLDG —ELECT _PLUMB
I hereby affirm that I am licensed under the provisions of Chapter 9(commencing —MECH—RESIDENTIAL X COMMERCIAL
with Section 7000)of Division 3 of the Business&Professions Code and that my
license is in full force and effect. JOB DESCRIPTION:
INSTALL(N)ILLUMINATED WALL SIGN(JAPAN HOUSE)AND(E)
I hereby affirm under penalty of perjury one of the following two declarations: BRANCH CIRCUIT
1. 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 REV#1-CHANGE NAME ON SIGN(CHARACTERS*HOT POT*)-
performance of the work for which this permit is issued. ISSUED 12/19/16
9 2. I"have and will maintain Worker's Compensation Insurance,as provided for by
t Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued. Sq.Ft Floor Area: Valuation:$2000.00
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 APN Number: Occupai cyType: =
and state laws relating to building construction,and hereby authorize 369 34 052
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 PERMIT EXPIRES WORK IS NOT STARTED
may accrue againstsaidCity in stands andce the hg oo this WITHIN 180 DAYS OF PERMIT ISSUANCE OR
Additionally,the applicant understands and will comply with all non-point
source regulations per the Cupertino Municipal-Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
l9S /VIM/Signature = Date 12/19/2016 Issued by:, /l1 M
Dot. ��
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of the -ROOFS:
following two reasons: All roofs shall be inspected prior tolany roofing material being installed.If a roof is
1. I,as owner of the property,or my employees with wages as their sole installed without first obtaining an spection,I agree to remove all new materials for
compensation,will do the work,and the structure is not intended or offered for inspection.
sale(Sec.7044,Business&Professions Code)
2. I,as owner of the property,am exclusively contracting with licensed Signature of Applicant: -�-
contractors to construct the project(Sec.7044,Business&Professions Code). Date:12/19/2016
I hereby affirm under penalty of perjury one of the following three declarations:
ALL ROOF COVERIN S TO BE CLASS"A"OR BETTER
1. 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. HAZARDOUS IJIATERIALS DISCLOSURE
2. I have and will maintain Worker's Compensation Insurance,as provided for by I have read the hazardous materials requirements under Chapter 6.95 of the
Section 3700 of the Labor Code,for the performance of the work for which this California Health&Safety Co e,Sections 25505,25533,and 25534. I will
permit is issued. maintain compliance with the Cu ertino Municipal Code,Chapter 9.12 and the
3. I certify that in the performance of the work for which this permit is issued,I Health&Safety Code,Section 5532(a)should I store or handle hazardous
shall not employ any person in any manner so as to become subject to the material.Additionally,should I u e equipment or devices which emit hazardous
air contaminants as defined by th Bay Area Air Quality Management District I
Worker's Compensation laws of California. If,after making this certificate of will maintain compliance with the upertino Municipal Code,Chapter 9.12 and
exemption,I become subject to the Worker's Compensation provisions of the the Health&Safety Co ,Sections 25505,25533,and 25534.
Labor Code,I must forthwith comply with such provisions or this permit shall
be deemed revoked. Owner or authorized agent: • 1,
APPLICANT CERTIFICATION
Date: 12/19/2016
I certify that I have read this application and state that the above information is CONSTRUCTION LENDING AGENCY
correct.I agree to comply with all city and county ordinances and state laws I hereby affirm that there is a construction lending agency for the performance
relating to building construction,and hereby authorize representatives of this city of work's for which this permit is issued(Sec.3097,Civ C.)
to enter upon the above mentioned property for inspection purposes. (We)agree Lender's Name
to save indemnify and keep harmless the City of Cupertino against liabilities,
judgments,costs,and expenses which may accrue against'said City in Lender's Address
consequence of the granting of this permit. Additionally,the applicant understands
and will comply with all non-point source regulations per the Cupertino Municipal ' t' Y
Code,Section 9.18. I understand my plans shall be used as public records.
Licensed
Signature Date 12/19/2016 Professional
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
)1149'
r.Is
10300 TORRE AVENUE,CUPERTINO,CA 95014-3255
NO
(408)777-3228•FAX(408)777-3333.buildingccupertino.orq
CUPERTI
❑NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION/TI REVISION/DEFERRED ORIGINAL PERMIT#_Zo/-U /(46 3
PROJECT ADDRESS ( .°--) g) S -. y�3 Lh4`
p_.,k- e_ . APN#
OWNER NAMEE-MAIL
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STREET ADDRESS
CITY, STATE,ZIP FAX
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CONTACT NAME I®A.0 PHONE E-MAIL.
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❑OWNER ❑ OWNER-BUILDER 0 OWNER AGENT R CONTRACTOR ❑CONTRACTOR AGENT 0 ARCHITECT D ENGINEER ❑ DEVELOPER 0 TENANT
CONTRACTOR NAME A 1,gZ.C' 14)`"&S.-
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COMPANY NAME E-MAIL � _
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ARCHITECT/ENGINEER NAME LICENSE NUMBER /2.„7& J BUS.LIC#
COMPANY NAME A--O c, pe$ ^ . E-MAIL ,F (b 65 .r... c4
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STREET ADDRESSrr'' 7` /!^r .�^ CITY,STATE,ZIP > PHONE
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DESCRIPTION OF WORK _ I A J / f
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EXISTING USE PROPOSED USECONSTR.TYPE #STORIES
C •.c[7^ USE TYPE OCC. SQ.FT. VALUATION($)
EXISTG NEW FLOOR DEMO TOTAL ¢, 6,.,
AREA AREA AREA NET AREA '- �-' ---
BATHROOM
BATHROOM KITCHEN OTHER
REMODEL AREA REMODEL AREA REMODEL AREA
PORCH AREA DECK AREA TOTAL DECK/PORCH AREA GARAGE AREA: 0 DETACH
0 ATTACH
#DWELLING UNITS: IS A SECOND UNIT DYES SECOND STORY ❑YES
BEING ADDED? ❑NO ADDITION? ❑NO -.MI _0111111111011111..'-
PRE-APPLICATION ❑YES IF YES,PROVIDE COPY OF IS THE BLDG AN +' _ _j-. , TOTAL VALUATION:
PLANNING APPL# o NO PLANNING APPROVAL LETTER EICHLER HOME? ❑NO - „�.
By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on the property owner's behalf. I ve read this
application and the information I have provided is correct. I have read the Description of Work and verify it is accurate. I ag4ee to comply with all applicable local
ordinances and state laws relating to building construction./I authorize representatives of Cupertino to enter the above-identified property for inspection purposes.
> �
Signature of Applicant/Agent: i� 7.-N”—i Date: � — 9 If) .
SUPPLEMENTAL INFORMATION REQUIRED PLAN CHECK TYPE I ROUTING SLIP
New SFD or Multifamily dwellings: Apply for demolition permit for ❑ OVER-THE-COUNTER 0 BUILDING PLAN REVIEW
existing building(s). Demolition permit is required prior to issuance of building
permit for new building. 0 EXPRESS 0 PLANNING PLAN REVIEW
Commercial Bldgs: Provide a completed Hazardous Materials Disclosure ❑ STANDARD 0 PUBLIC WORKS
form if any Hazardous Materials are being used as part of this project. ❑ LARGE ❑ FIRE DEPT
Copy of Planning Approval Letter or Meeting with Planning prior to
submittal of Building Permit application. ❑ MAJOR ❑ SANITARY SEWER DISTRICT.
0 ENVIRONMENTAL HEALTH
BIdgApp_2011.doc revised 06/21/11