B-2016-1738 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2016-1738
10222 PARLETT PL CUPERTINO,CA 95014-2208(316 26 061) A R CONTRACTOR
SAN JOSE,CA 95109
OWNER'S NAME: UTSUMI GARY E AND PATSY M TRUSTEE DATE ISSUED:04/11/2016
OWNER'S PHONE: PHONE NO:(408)656-5610
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class GENERAL BUILDING CONTRACTOR Lic.#803483
Contractor A R CONTRACTOR Date 01/31/2018 X BLDG —ELECT —PLUMB
MECH X RESIDENTIAL COMMERCIAL
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. JOB DESCRIPTION:
MASTER BEDROOM BATHROOM REMODEL 114 SQ.FT.,CHANGE
I hereby affirm under penalty of perjury one of the following two declarations: TUB TO SHOWER,NEW FIXTURES.
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.
2. 1 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. I Sq.Ft Floor Area: Valuation:$6000.00
APPLICANT CERTIFICATION
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 316 26 061
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 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/918. 180 DAYS FROM LAST CALLED INSPECTION.
Signature Date %��Z I� Issued by:Abbyey nde
Date:04/11/2016
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
r. 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)
2. 1,as owner of the property,am exclusively contracting with licensed Signature of Applicant:
contractors to construct the project(Sec.7044,Business&Professions Code). Date:
I hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
r. 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.. I will
permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
a. 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
shall not employ any person in any manner so as to become subject to the material. Additionally,should I use equipment or devices which emit hazardous
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 �authonzeent'
Sections 25505,25533,and 25534.
Labor Code,I must forthwith comply with such provisions or this permit shall �Ow_ner
be deemed revoked.
APPLICANT CERTIFICATION Date:
I certify that I have read this application and state that the above information is CONSTRUCTION LENDING AGENCY
I hereby affirm that there is
correct.I agree to comply with all city and county ordinances and state laws 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
I understand my plans shall be used as public records.
Code,Section 9.18.
Licensed
Signature Date Professional
CONSTRUCTION PERMIT APPLICATION
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COMMUNITY DEVELOPMENT DEPARTMENT� BUILDING DIVISION 10300 TORRE AVENUE• CUPERTINO, CA 95014-3255' B
CUPERTINO (408) 777-3228• FAX(408)777-3333- buildingDcuoertino.org R wt m
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DESCRIPTIO'!; F lfOTtK S I r� �z,,
E.ISTING USE PROPOSED USE CONSTR.WP= _STORIES {
Y+-� __1_{ O��� USE I TYPE I OCC. I SQ.FT. I V.4Lli ATIO (S)
ERISTGNEN FLOOR s DEMO c TOTAL 111
AREA !g 17 4/ 1 AK �7
EA j I i). AREA NET AREA
o / '
BATHROOM KITCHEN OTHER
REAIODEL.AREA RFMODELAREA REMODELAREA.
� �u
PORCH.AREA DECK- EA TOTAL DECKPORCH AREA G P-,GE ARFA: U DETACH
[]ATTACH
DNVELLINGUNITS: 1S A SECOND UNIT- ❑YES SECOND STORY ❑YES I J
BEING ADDED? ONO ADDITION? ❑1,•O
PRE-AF?LIGATION ❑YES IF YRS,PROVIDE COPY OF IS THE BLDG AN []YES ES VED BZ �-*2� <s �� I TOTAL VALUATION:
PL.AKNING APPL m F NO PLANNING APPROVAL LETTER I EICHLER HOME? Q?s0 � a E'er .� Onp�
? 5 A if,. �i}�lP l{tf
By my si_na ure below,I certify to each of the follovwine: I am the propem,oti ner or authorized zgent to act o the property owner's behalf. I have read chis
application and the information I have provided is correct. I have read the Description of Work and verify it is accurate. I a`*ree to comply with all applicabl e local
ordinances and state]ay.•s relating to t:ding construction. I authorize representatives of Cupet vino to enter the�abyove-identified property.for inspection purposes.
Signature of Applicant!Agents
SUPPLEMfENTAL P'�FOR14ATION RE IJTRED
Q ROIJTI\G,SLIP
New SFD or Alultifamil dttellinQs: Apply for demolition permit for
D�OS ER TI-TE COUNTER x BUILDI\G PLA\RE1 IL1i'
existing building(s). Demolition permit is required prior to issuance of building
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permit far nett building, nREss y=£ }IPLAZI� G PLA7�REYI£Si
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_Commercial Bldgs: Provide a Completed Hazardous Materials Disclosure
yt
i01i11 if ally Hazardous Materials are beina used 2S DEIL of this project. � a
I� LAPGE z £ FIR£DEPT i�4C� r r
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Copy of PlamIing Approval Letter or Meeting with Planning prior to
P5 PP ]] M1L4JOI2 s r ❑ S4VTAR]SER ERD]STRICT
submittal of Building Permit application.
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