B-2016-2160CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: I
CONTRACTOR:
PERMIT NO: B-2016-2160
10249 AINSWORTH DR CUPERTINO, CA 95014-1001 (326 13 13 1)
THRASHER TERMITE
& PEST CONTROL
17427 FARLEY RD
WEST
OWNER'S NAME: BIAVA SHAWNA R TRUSTEE
DATE ISSUED: 06/17/2016
OWNER'S PHONE: 408-206-0889
PHONE NO: 408-354-9944
LICENSED CONTRACTOR'S DECLARATION
BUILDING PERMIT INFO:
License Class SPCB Lic. #PR5009
X BLDG
Contractor THRASHER TERMITE & PEST CONTROL Date
_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:
DRY ROT REPAIR AT MASTER BATHROOM SHOWER - REPLACE
I hereby affirm under penalty of perjury one of the following two declarations:
SHEETROCK, TILES, SHOWER PAN, AND SHOWER FIXTURE (LIKE
1. I have and will maintain a certificate of consent to self-insure for Worker's
FOR LIKE)
Compensation, as provided for by Section 3700 of the Labor Code, for the
performance of the work for which this permit is issued.
2. 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
Sq. Ft Floor Area:
Valuation: $4500.00
permit is issued.
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 13 131
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 1S0 DAYS OF PERMIT ISSUANCE OR
Additionally, the applicant understands and will comply with all non-point
source regulatio. per the Cupertino nicipal Code, Section 9.18.
180 DAYS FROM LAST CALLED INSPECTION.
f /
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25)"
Si nature Date C
Issued by: Phuong Devrie
Date: 06/17/2016
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)
2. I, as owner of the property, am exclusively contracting with licensed
Signature of Applicant:
contractors to construct the project (Sce.7044, Business & Professions Code).
Date:
I hereby affirm under penalty of perjury one of the fallowing 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 Code, Sections 25505, 25533, and 25534. I will
eatSafety
Hh &
l
permit is issued.
maintain compliance with the Cupertino 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 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 Co , Sections 25505, 2553 n 5534.
Labor Code, I must forthwith comply with such provisions or this permit shall
be deemed revoked.
Owner or autho ' ed age
APPLICANT CERTIFICATION
Date:
(—C6NSTRJCTION
I certify that I have read this application and state that the above information is
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
ARCHITECT'S DECLARATION
Code, Section 9.18.
1 understand my plans shall be used as public records.
Licensed
Signature Date
Professional
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
GUi' RiCNO (408) 777-3228 • FAX (408) �77-3333 • buildin c cupertinaora
❑ NEW CONSTRUCTION ❑ ADDITION ALTERATION/ Tl [:1 REVISION/ DEFERRED ORIGINAL PERMIT #____—_
PROJECT ADDRESS e APN# �, n
OWNER NAME W AA- B PHONE I I ^ � / n PPj E-MAIL
STREET ADDRESS CITY, STATE, ZIP FAX
CONTACT NAME --r--- PHONE 1
)E-MAI�Y�7�_
STREET ADDRESS ^ CITY STATECZIP f.
FAX
El OWNER 1:1 OWNER -BUILDER OWNERAGENT CONTRACTOR ❑ CONTRACTOR AGENT ElARCHITECT ❑ ENGINEER 1:1DEVELOPER ❑ /TENANT
CONTRACTONAM� Peat
T &L, �� LICENSEER_O, LIC NSE BUS. LIC #46
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COMPANY NAME E-MAIL FAX
STREET ADDRESSI` vW/l I A 1 n C N QPHON
ARCHITECTBNGINEER NAME LICENSE NUMBF,R ` BUS. LIC #
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY, STATE, ZIP PHONE
DESCRIPTION OF WORK
v tveM &ft*&VM I --Z- S/ r
EXISTING USEPROPOSED USE CONSTR.
TYPE # STORIES
II
USE
TYPE
! OCC.
SQ FT.
VALUATION ($
NEW FLOOR
DEMO
TOTAL
AREAC.
AREA
AREA
AREA
NET AREA
BATHROOM
KITCHEN
OTHER
'
REMODEL AREA
REMODELAREA
REMODEL AREA
PORCH AREA DECK AREA
TOTAL DECK/PORCH AREA
GARAGE AREA: ❑ DETACH
0 ATTACH
# DWELLING UNITS:
IS A SECOND UNIT ❑ YES
SECOND STORY ❑ YES
V- V
BEING ADDED? ONO
ADDITION? ❑ NO
PRE -APPLICATION ❑YES IF YES, PROVIDE COPY OF
IS THE BLDG AN ❑YES
A,I
TOTAL VALU O
PLANNING APPL # ❑ NO PLANNING APPROVAL LETTER.
EICHLER HOME? ❑ NO
x
By my signature below, I certify to each of the following: I am the property owner or auth , ed ager to act)m the4property owner's behalf. I have read this
application and the information I have pr Ided is correct. I have read the Description of Work aild verify Is accurate. I agree to comply with all applicable local
ordinances and state laws rel f in�gc ns tion�Itho a .p esentatives o .upert. o to enter the above'dentified pei7r inspection purposes.
/[/ r
Signature ofApplicant/ ent. �Date: _—
— R
SUPPALMERTAIII INFORMATION REQUIRED
PLAN CHECK T,YPE,,,
❑., pvER THE coUNTER
❑ soH DING KLAN RE"viEw
_ New SFD or Multifamily dwellings: Apply for demolition permit for
existing building(s). Demolition permit is required prior to issuance of building
permit for new building.
❑ TXPRES3 �
❑'PLANNING PLAN REVIEW
Commercial Bldgs:. Provide a completed Hazardous Materials Disclosure
❑ STANDARD
❑ PUBLIC WORk`s
_
form if any Hazardous Materials are being used as part of this project.
❑ ;LARGE
❑ FIRE DEPT
Copy of Planning Approval Letter or Meeting with Planking prior to
❑' MAJOR
❑SANITARY$EVIERDISTRIGT .w
submittal of Building Permit application.
BldgApp_201 Tdoe revised 06/21111