B-2016-2021 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2016-2021
21805 REGNART RD CUPERTINO,CA 950144840(366 34 001) HOME REMODELERS
DESIGN&BUILD INC
DANVILLE,CA 94506
OWNER'S NAME: CIANO ROBERT L TRUSTEE&ET AL DATE ISSUED:05/25/2016
OWNER'S PHONE:4082572502 PHONE NO:(925)648-1251
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class B Lic.# 74048
Contractor HOME REMODELERS DESIGN&BUILD INC Date 06/30/2016 X BLDG ELECT X 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:
KITCHEN REMODEL(212 S.F.);INSTALL(N)PROPERTY LINE
I hereby affirm under penalty,of perjury one of the following two declarations: CLEAN-OUT(CUPERTINO SANITARY)
1. 1 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
Y. performance of the work for which this permit is issued. N in no A
(2. I have and will maintain Worker's Compensation Insurance,as provided for by
f Section 3700 of the Labor Code,for the performance of the work-for which this
SIAKII I /ApV
permit is issued. Ia
Sq.Ft Floor Are , Val :$5' 0 . 0
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 366 34 001
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 1.80 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 LASTCALLED INSPECTION.
Signature 0Date 05/25/2016 Issued by:PAUL O'SULLIVAN
Date:05/25/20f6
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)
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:05/25/2016
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. 1 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
3. 1 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 the Health&Safety Code,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:
APPLICANT CERTIFICATION Date:05/25/2016
I certify that I have read this application and state that the above information is CO STR T N —JiL 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. I understand my plans shall be used as public records.
Licensed
Signature Date 05/25/2016 Professional
CONSTRUCTION PERMIT APPLICATION ��-RCGI
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO,CA 95014-3255
(408)777-3228•FAX(408)777-3333•building(a)cupertino.org
❑NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION/TI REVISION/DEFERRED ORIGINAL PERMIT
PROJECT ADDRESS e7 i/,V APN# �J✓O �'
OWNERNAME S•+ 't " PHONE E-MAIL
STREET ADDRESSr— P11
Y,STATE,ZIP ryry FAX
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CONTACT NAME PH E- II
STREET ADDRES -1 01
CITY,STAT ZIP p AXp.,�
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❑OWNER ❑ OWNER-BUILDER ❑ OWNERAGENT CONTRACTOR ❑CONTRACTORAGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME LICENSE LICENSE TYPE BUS.LIC
COMPANY NAME ( LI F
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STREET ADDRESS ' Q CITY,ST E,.ZIP a ,,,_ PHONE
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ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC#
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
DESCRIPTION OF WORK &t'wd ,
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USE POSED USE CONSTR.TYPE #STORIES ` .OFFICE USE ONI.
OCC. «TYPE DESCRIPTION "S .FT." VALUATION
EXISTG NEW FLOOR DEMO TOTAL
AREA AREA AREA NET AREA
BATHROOM KITCHEN ' OTHER
REMODEL AREA :REMODEL AREA REMODEL AREA '
PORCH AREA DECK AREA TOTAL DECK/PORCH AREA GARAGE AREA:❑ DETACH
❑ ATTACH
S DWELLING UNITS: IS A SECOND UNIT ❑YES. SECOND STORY ❑YES "
BEINGADDED? ❑NO ADDITION? ❑NO
PRE-APPLICATION ❑ YES IF YES,PROVIDE COPY OF PLANNER'S NAME: RECEIVEDBY'
PLANNING APPLrt ❑ NO PLANNING APPROVAL LETTER '
9'
By my signature below,I certify to each of the following: I am the property owner or authorized ageift to act on M 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 rely' g to building constru do I authorize repres tat es of Cupertino to enter the above-identified property for inspection purposes.
Signature ofAppheant/Agent:AM 4 4 4Date:
SUPPLEMERAL INJIMMATION REQUIRED 'PLAN CHECIC'TYPE ,_.RauTiN�sLIPI,
_New SFD or Multifamily dwellings: Apply for demolition permit for 'OVERTHE-COUNTER B1jILDINGPLANREVIEw
existing building(s). Demolition permit is required prior to issuance of building
permit for new building. ❑:4x""''Ss PLAN
_Commercial Bldgs: Provide a completed Hazardous Materials Disclosure 'risLlcwoRs
,
form if any Hazardous Materials are being used as part of this project.
❑:TARGE ,_- ❑�,FIAI IfEPT
Copy of Planning Approval Letter or Meeting with Planning prior to '
❑ MATOR ❑ SANJTARYSEWERDTSTRICT
submittal of Building Permit application. -
❑ EN1rIRONMENTALHEALTH
BldgApp_2011.doe revised 03116111
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Wi0v� _ APPROVED
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