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B-2016-1630 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2016-1630 21114 GREENLEAF DR CUPERTINO,CA 95014-1622(326 28 098) PACIFIC CONSTRUCTION& DESIGN CALABASAS,CA 91302 OWNER'S NAME: KIMURA TAIKO AND KAZUO DATE ISSUED:03/25/2016 OWNER'S PHONE:408-725-8264 PHONE NO:(818)880-1466 LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: License Class GENERAL BUILDING CONTRACTOR Lic.#1Q8�1Q4 Contractor PACIFIC CONSTRUCTION&DESIGN Date 10/31/2017 X BLDG X ELECT X PLUMB I hereby affirm that I am licensed under the provisions of Chapter 9(commencing MECH X RESIDENTIAL COMMERCIAL with Section 7000)of Division 3 of the Business&Professions Code and that my license is in full force and effect. JOB DESCRIPTION: REMODEL/RECONFIGURE(E)68 S.F.MASTER BATH(NON- I hereby affirm under penalty of perjury one of the following two declarations: STRUCTURAL),ADD 6(N)RECESSED LIGHTS IN KITCHEN AND 1. I have and will maintain a certificate of consent to self-insure for Worker's REPLACE SINK IN KITCHEN Compensation,as provided for by Section 3700 of the Labor Code,for the erformance of the work for which this permit is issued. z. 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. Sq.Ft Floor Area: Valuation:$9000.00 APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is correct.I agree to comply with all city and county ordinances APN Number: Occupancy Type: and state laws relating to building construction,and hereby authorize 326 28 098 representatives of this city to enter upon the above mentioned property for inspection purposes. (We)agree to save indemnify and keep harmless the City of Cupertino against liabilities,judgments,costs,and expenses which PERMIT EXPIRES IF WORK IS NOT STARTED may accrue against said City in consequence of the granting of this permit. WITHIN 18�DAYS OF PERMIT ISSUANCE OR Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Mu 'pat/ode,Section 9.18. ]$O DAYS FROM LAST CALLED ECTION. Signatur Date 03/25/2016 Issued b . Date:03/25/2016 OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for one of the RE-ROOFS: following two reasons: All roofs shall be inspected prior to any 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 inspection,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) z. 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:03/25/2016 I hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS 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 MATERIALS 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 Code,Sections 25505,25533,and 25534. 1 will permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the s. I certify that in the performance of the work for which this permit is issued,I Health&Safety Code,Section 25532(a)should I store or handle hazardous material. Additionally,should I use equipment or devices which emit hazardous shall not employ any person in any manner so as to become subject to the air contaminants as defined by the Bay Area Air Quality Management District I Worker's Compensation laws of California. If,after making this certificate of will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and exemption,I become subject to the Worker's Compensation provisions of the the Health&Safety Code, ections 25505,25533,and 25534. Labor Code,I must forthwith comply with such provisions or this permit shall be deemed revoked. Owner or authorized agent: /24c= APPLICANT CERTIFICATION Date:03/25/2016 1 certify that I have read this application and state that the above information is CONSTRUCTIO DING 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 ARCHITECT'S DECLARATION Code,Section 9.18. 1 understand my plans shall be used as public records. Licensed Signature Date 03/25/2016 CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION 10300 TORRE AVENUE• CUPERTINO, CA 95014-3255 CUPERTINO (408) 777-3228 • FAX(408)777-3333 • building(�cupertino.org r C(o 3 ❑NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION/TI ❑ REVISION/DEFERRED ORIGINAL PEP—=f PROJECT ADDRESS nn C1J� APN R -3 OWNERNAME —ra v o PHONE W ^ 6 E-MAIL r STREET ADDRESS. ' 1 ��_ . CITY, STATE,ZIP �yo I) I FAX CONTACT NAME PHONE rZR E-1 I4IL STREET ADDRESS CITY,STATE, ZIP FAX ❑ OWNER ❑ ORNQER-BUILDER ❑ OMWERAGENT CONTRACTOR ❑CONTRACTORAGENT ❑ ARCHITECT ❑ENGA'EER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME ` G►I'�� LICENSE NbMBER/ Q' A LICENSE TYPE BUS.LIC R C0NIPANY NAME �� E-MAIL FAX —r STREET ADDRESS CITY,STATE,ZIP PHONE ARCHITECT,'ENGINEER NAME LICENSE\WiBER BUS.LIC R COMPANY NAME E-?%AIL FAX STREET ADDRESS CITY,STATE,ZIP I PHONE DESCRIPTION of WOra E?i1STI?QG USE PROPOSEDUSE CONSTR.T1 PE =STORIES f� USE TYPE OCC. SQ.FT. I VALUATIONT(S) EXISTG NEW FLOOR DEMO TOTAL , AREA AREA AREA 1 ET.AREA 019 BATHR0014 KITCHEN I OTHER REIAODELAREA REMODELAREA REMODELAREA PORCH AREA DE EA TOT-AL DECK/PORCH AREA GARAGE AREA: DETACH []ATTACH DWELLING UNITS: IS A SECOND UNIT []YES SECOND STORY [:])'-ES BEING ADDED? ❑NO ADDITION? EJ NO PRE-.APPLIC.ATION ❑1'ES IF YES,PP.O\%IDE COPY OF IS THE BLDG.4N ❑1'ES RIC ] TOTAL VALUATION: PLAT�IeING.APPLm ❑N0 PLATNINGAPPROV,4LLETTER EICHLERHOATE? ❑NO By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on t e property owner's behalf. I have read this, application and the information I have provided is correct. I have read the Description of'Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating to building construction. I authorize representatives of Cupertino to enter the above-id ntifie pro erty.for inspection purposes. Signature of Applicant/Agent: Date: SUPPLEMENTAL INF0P2\7A .QUIRED -\Tete SFD or Multifamily dwellings: Apply for delnoliu'bn-permit for k 3 ' ❑ O]ER THE COU\TER ❑ BUILDI\G PLA\RE\IE\� existing building(s). Demolition peiTmt is required prior to Issuance of buildmQ Hx , h � permit for new building. ❑ ECPRESS � } ` - Y ❑ PI 4\\L\G PLA\REQ IE\6 vx. K 4. _Commercial Bldgs: Provide a completed Hazardous Materials Disclosure ❑ sT4\D4RD x❑ PUBLIC\NORT.S form if any Hazardous Materials are being used as part of this project. \L4RGEs FIP.E DEPT £` v s , u r 3 _Copy of Plaiming Approval Letter or Meeting with Planning prior to t submittal of Building Permit application. v y TL4JOR ❑ SA\IT4R]SE\'ER DISTRICT ❑.,E\\7R0\1iE\T.4L HEALTH Bldg-4pp_011.doc revised 06121/11 : 2C� i ` ti. �� '� `tea M _ _ �.c • j , I 1 ar k4i I O : I i oM��UNITY DR- VISION _ ,PPJIENT DEPARTMENT ._.. BUILDING DIVISION-CUPERTINO _ be — This set c?t plans and sa „tic-'at.a t!1UST 1tPnt at the — __------�— m; any K / -- ----- - --- ------ -- t.s�-1t iu fC�I,�u{t - ------- - Of tC?t.±3VlG.G -. Oft 21� tJzi ,I�n"l tJl 1311(1 f tl?oYF.ri I I ,I i Tli? F","fir L t v W. : •�s�r�_. a �;,I — 'c r , , A C lJ PE RTI NO i '�Lildi n9 Departmentr KiAR 2 5_2016 ti 00 c; REVIEWED FOR CODE COMPLIANCE Reviewed By: �i : i