09040105 - PUBPOP T(f4 1)
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Permit Information
Permit Number `
09040105
Status "
v
Master Number
�J
Notes i 1
Project
Apply Date "
04/21/2009
Operator patg
Permit Issue Date
04/21/2009
Operator patg
Certificate Issued
06/26/2009
Operator IF
Certificate Type
Certificate Number
Permit Property Zoning Applicant ContractorDefined Fields
Permit Details
Permit Type ` 1R3SFDREM []
SINGLE FAMILY DWELLING REMODEL
Usage Class " II/III B
II/III B IV HT V B NEW - -- --- -- -
Applied Value "
120000
SQUARE FT.
288_
Calculated Value
0
US C-404 Type
434
SALT: RESIDENTIAL
Permit Form
r UTOPERM - PERMIT
Ownership
1 - Private
Project Size
COUNTER -OVER THE COUNTER
V
Location Information
Address 21384 DEXTER DR
City/State/Zip CUPERTINO I `CA 95014
APN 32� 641068.00 -- -- j
U nit
Ovmer Entity Information
lOwnerName'l ROB & LAURA TSUK
Use Default ❑
Address Home - 21384 DEXTER DR •�
City/State/Zip CUPERTINO CA CA 95014.1317
Purpose/Special Conditions
RMV/RPLC/RiDL(288)KTCHN,BTH;NO NEW FIXTRWITH EXT;N
RE-RF OR STRCTRL
FILMED-2011
J[EAdd Default T
v
toO OK
Back
ea Contractors
Fees
Plan Reviews
la Inspections
149 Print Permit
Adjustments
l Holds
l Copy Permit
(;i Close Permit
u
k Overrides
Supplemental Fields
Notes
Ifni Attachments
'ermit issued 04/21 /2009 i'1R
nter permit status
Dz
0
CITY OF CUPERTINO
BUILDING DIVISION PERA41T
-
1 I
BUILDING ADDRESS:
PERMIT NO.
21384 DEXTER
STEVENS
OWNER'S NAME:
PERMIT ISSUE DATE
PHONE:
A CONTROL NO.
(408) 287-4088
ARCHITECrfENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 7000) of Division 3 of the Business and Professions Code, and my license is
in full force and effect 5.7 -
RMV / RPLC / RMDL (2 8 8) KTCHN r BTH ; NO NEW F I XTRWI TH
License Class Lk, M
Date U 1t -o ti Contractor
EXT ; NO RE-RF OR STRCTRL
� CHITECPs DECLARATION
1 understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
l hereby affirm that I am exempt from the Contractor's License Law for the
following mason. (Section 7031.5, Business and Professions Code: Any city or county
which requires a permit to construct, alter, improve, demolish, or repair any structure
prior to is issuance, also requires the applicant for such permit to file a signed statement
that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
Sq. Ft. Floor Area
Valuation
(commencing with Section 70M of Division 3 of the Business and Professions Code) or
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
12 0 0 0 0
APN Number
Occupancy T
P Y Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars (S WI.
32641068.00
❑ L as owner of the property, or my employees with wages as their sole compensation,
Required Inspections
will do the work, and the strucwm is not intended or offend for sale (Sec. 7044, Business
and Professions Code: The Contractors License Law does not apply to an owner or
property who bu0ds or improves thereon, and who does such work himself or through his
own employees, provided that such improvements are not intended or offered for sale. If,
however, the building or improvement is sold within one year of completion, the owner -
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑ 1, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec. 7044, Business and Professions Code:) The Contractor's Li-
eonse law does not apply to an owner of property who builds or improves thereon, and
who contracts for such projects with a contractor(s) licensed pursuant to the Contractor's
License Law.
❑ I am exempt under Sec , B & P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
l hereby attirm under penalty of perjury one of the following declarations:
❑ I have and will maintain a Certificate of Conscnt to self -insure for Worker's Compen-
sation, 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 required by Section
3700 of the Labor Code, for the performance of the work for which this permit is Issued
My Workeess�••Insurance prier and Policy number am:
l'Compensation
Cartier. J- Policy No.: �3� 0 0 (I �a-7
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thissection need not be completed if Ibe permit Is foronc hundred dollars ($I00)
or less)
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 Workers' Compensation
Laws of California. Dam
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
become subject to the Worker's Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of
the work for which this permit is issued (Sec. 3097, Civ, C.)
Lender's Name
'
Lender's Address
I certify that I have read this application and stain 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
liabilitles,judgments, costs and expenses which may in any way accrue against said City
inconsequence of Ih granting of this pernhiL
APPLICANT U STANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date /
SOURCERE TIONS.
Re -roofs
—
Type of Roof
'0
Signature ofAp t t/ConuactorS Date
AZAADOUMATERIALS DISCLOSURE
Will the ii`pK1 t or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code, Chapter 9.12. and the Health and Safety
Code, scorers 25532(a)? ❑Yes ,,,,/''
lg+ro
All roofs shall be inspected prior to any roofing ma rial being installed.
If a roof is installed without first obtaining an inspecti n, I agree to remove
Will the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants as derrned by the Bay Area Air Quality Management
all new materials for inspection.
District?
❑Yes *0
I have read the hazardous materials requirements under Chapter 6,95 of the Califor-
nia Health & Safety Code, Sections 25505, 25533 and 25534.1 understand that if the building
does not current have a tenant at It a my responsibility to notify the occupant of the
requirements ch must t prior to issuance of a certificate of occupancy.
Signature of Applicant Date
�2 "
All roof coverings to be Class tt " or better
g n
Owner of au ri d agent Dam