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B-2016-2233 (2) CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: CONTRACTOR: PERMI r NO B-2016-2233 826 SEPTEMBER DR CUPERTINO,CA 950144127(362 14 021) SUMMIT REMODELING CO INC CAMPBELL,CA 95008 OWNER'S NAME: SALEM JESSE RAND PATRICIA L TRUSTEE DATEISSUED:06/29/2016 OWNER'S PHONE:408-499-5777 PHONE O:(408)377-5252 LICENSED CONIRACTOR'S DECLARATION BUILDING PERMIT INFO: License Class GENERAL BUILDING CONTRACTOR Lie.4361551 Contractor SUMMIT REMODELING CO INC Date 07/31/2018 X BLDG _ELECT _PL 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: I hereby affirm under penalty of perjury one of the following two declarations: BATHROOM REMODEL;2ND FLOOR BATHROM-(43 S.F.) 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. I have and will maintain Worker's Compensation Insurance,as provided for by Section 3700 of the tabor Code,for the performance of the work for which this permit is issued. Sq.Ft Floor Area: Valuatio :$10000.00 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: Occupa cy Type: and state laws relating to building construction,and hereby authorize 362 14 021 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 I F WORK IS NOT STARTED may accrue against said City in consequence of the granting of this permit. WITHIN 180 DAYS F PERMIT,I SUANCE 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 LAST CALLED INSPECTION. Sigri t re t 1�P Date /6 29/2016 Issued by:AbbvAyende y� 4 Date:06/29/2016 r AA i. OWNER-BUILD RD .CLARATmN I hereby affirm that I am exempt from the Contractor's License Law for one of the ' following two reasons: All roofs shall be inspected prior tc any roofing material being installed.If a roof is t. 1,as owner of the property,or my employees with wages as their sole installed without first obtaining an ii spection,I agree to ren Love 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:6/29/2016 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 IATERIALSDISCLOSURE 2. I have and will maintain Worker's Compensation Insurance,as provided for by I have read the hazardous matei ials 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 Coo le,Sections 25505,25 33,and 25534. I will permit is issued. maintain compliance with the Cu ertino Municipal Code,Chapter 9.12 and the s. 1 certify that in the performance of the work for which this permit is issued,I Health&Safety Code,Section 5532(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 u e equipment or devic s which emit hazardous air contaminants as defined by th 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 a ions 25505,255 3,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:6/29/2016 Icertify that I have read this application and state that the above information is CONSTRUCT[ON LENDING correct.I agree to comply with all city and county ordinances and state laws I hereby affirm that there is a con;truction 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 ARCHITE JIS DECLARATIO Code,Section 9.18. I understand my plans shall be u ed as public records. Licensed Signature Date 6/29/2016 Professional CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO,CA 95014-3255 CUPERTINC3 (408)777-3228•FAX(408)777-3333•building@cupertino.org QZT 33 ❑NEW CONSTRUCTION ❑ ADDITION ❑ALTERATION/Ti ❑' REVISION/DEFERRED QRIGINAL PERMIT# PROJECT ADDRESS45a& setew6eC 'Tv APN# Z>UZ Ict 0 i 1 PIIONE STREET ADDRESS CITY, STATE,ZIP i FAX CONTACT NAME PHONE'�O`I _o+�p� EMAILYrbk►� MG��'-C STREET ADDRESS 3$t MCG I; t CITY,STATE,UP /1� a s-V � FAX ®OWNER ❑ OWNER-BUILDER 11OWNERAGENT ••,CONTRACTOR ❑CONTRACTORAGENT El1ARCHITECT` ❑INGINEER ❑ DEVELOPER ❑TENANT CONTRACTOR NAME r-i "ur r LICENSE NUMBER LICENSE TYPE BUS,LIC# a e s COMPANY NAME NII>i t M `c rC. E MAII 4%%6A's Were rek"l I-c 104% FAX STREET ADDRESS �m• F— ACOGI- EM/K L&% CITY,STATE,ZIP00. 6-A •69 PHONE '37 qq ARCHITECT/ENGINEER NAME A t' LICENSE NUMBER ( BUS.LIC# COMPANY NAME Iv E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE DESCRIPTION OF WORK N16%'05- �(�'1 IAD �� rC e(. _q,6r las of `a Kr� lnp v awr v `tta EXISTING USE PROPOSED USE CONSTR.TYPE #STORIES USE TYPE 0 C. SQ.FT. VALUATION($) "EXISTG NEW FLOOR DEMO TOTAL AREA AREA AREA NETAREA BATHROOM - A KITCHEN OTHER REMODEL AREA REMODEL AREA. REMODEL AREA PORCH AREA DECKAREA 7TOTALDECKWORCH AREA GARAGE AREA: DETACH ❑ATTACH #DWELLINGUNTTS: IS A SECOND UNIT ❑YES SECOND STORY OYES BEINGADDED? ,WO ADDITION? Ageo PRE-APPLICATION El YES IF YES,PROVIDE COPY OF IS THE BLDG AN ❑YES IZE D BY: Nimn AL V UATION: PLANNING APPL#. ONO PLANNING APPROVAL LETTER EICHLERHOME? ,f'NO By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on the 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 a 3plicable local ordinances and state laws relating to building cons ction. I au horize representatives of Cupertino to enter the above-identifi`d property for inspec on purposes. tt Signature of Applicant/Agent: Date: (0–al— LP SUPPLEMENTAL INFORMATION REQUIRED PLAN CHECK TYPE Roun NG SLIP _New SFD or Multifamily dwellings: Apply for demolition permit for p OVER-TH&COU ITER CI BUILDING PL REVIEW existing building(s). Demolition permit is required prior to issuance of building permit for new building, ❑ ExPREss II PLANNINGPL4NREVIEW _Commercial Bldgs: Provide a completed Hazardous Materials Disclosure 11STANDARD 171 PUBLIC WO form if any Hazardous Materials are being used as part of this project. ❑ LARGE ❑ FHLE DEPT _Copy of Planning Approval Letter or Meeting with Planning prior to 1 MAJOR ❑ SANITARYSEIVERDISTRICT submittal of Building Permit application. Q ENViRoNMEN rAL HEALTH 7�ldg4pp.,�011.doc revised 06121111