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B-2016-2317CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: CONTRACTOR; PERMIT NO: B-2016-2317 21757 MCCLELLAN RD CUPERTINO, CA 95014-4053 (357 19 062) PRUDHON BUILDERS SCOTTS VALLEY, CA 95066 OWNER'S NAME: TRISNADI JAI -UA I AND KRISTINA W TRUSTEE DATE ISSUED: 07/14/2016 OWNER'S PHONE: 408-369-6885 PHONE NO: (408) 390-7251 LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: License Class B Lic. #776376 Contractor PRUDHON BUILDERS Date 03/31/2018 X BLDG ELECT 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 KITCHEN - MEP (176 S.F.); REMODEL MASTER I hereby affirm under penalty of perjury one of the following two declarations: BATHROOM - MEP (40 S.F.); REMODEL HALL BATH - MEP (60 S.F.); 1. 1 have and will maintain a certificate of consent to self -insure for Worker's REMOVE AND REPLACE WINDOWS IN MASTER BATHROOM AND Compensation, as provided for by Section 3700 of the Labor Code, for the HALL BATHROOM (NO STRUCTURAL CHANGES) performance of the work for which this permit is issued. ave 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; $100000.00 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 tobuildingconstruction, and hereby authorize 357 19 062 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 appl'cant unde nds and will comply with all non -point source regulation er the C e mo Municipal Code, Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION. Signat rife-� Date 07/14/2016 �. Issued by; PAUL O'SULLIVANir lx S��x ku —Z Date: 07/14/2016 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 properly; am exclusively contracting with licensed Signature of Applicant: contractors to construct the project (Sec.7044, Business & Professions Code). Date: 07/14/2016 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 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 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 Cup � o Munici , Chapter 9.12 and exemption, I become subject to the Worker's Compensation provisions of the the Health &Safety Code, -S et' s 2550 , 5 3, nd 25534. Labor Code, I must forthwith comply with such provisions or this permit shall be deemed revoked. Owner or authorized agent APPLICANT CERTIFICATION Date: 07/14/2016 certify that I have read this application and state that the above information is CONSTRUCTI LENDING A EN Y 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 07/14/2016 Professional E)90 6 '•' z CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 +CUPERTIN I (408) 777-3228 • FAX (408)V77-3333 • buildingCcDcupertino.org ❑ NEW CONSTRUCTION ❑ ADDITION ALTERATION TI ❑ REVISION/ DEFERRED ORIGINAL PERMIT # PROJECT ADDRESS ` // /` APN # 3L9 t (� OWNERNAME rm i a ONE ��e_ o3(q- E-MAIL STREET ADDRESS q B, V � ( At,_C teles CITY, STATE, 7�I Q e FAX 1l t � `sol °'T CONTACT NAME PHO b 08) 1 q® ` 9 gID e)i , STREET ADDRESS 7. �/ N V F"+ i✓ SC� TE' ZIP �5 FAX ❑ OWNER ❑ OWNER -BUILDER ❑ OWNER AGENT J' CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ T CONTRACTORN ME !ArjV LICEN B Raj LICENSE TYPE -ENANT BUS -LIC# �' 95. COMPANYN`pyj��'Jyp �g pt Qg �} ! � 9 ! . %..�� _. E-MAIL \E@ d�'ppQy 6-°R r. ta" `� '^'� •61 4M"hA+ 9im� d� FAX PHONE STREET ADDRESS ! CITY, STATE, ZIP" ARCHITECT/ENGINEER E LICENNUMBER S. LIC # COMPANY NAME E -MAI F STREET ADDRESS CITY, STATE, Z114%,'., PHONE DESCRIPTION OF WORK W EXISTING USE PROPOSED USECONSTR. TYPE # STORIES USE TYPE OCC. SQ.FT. VALUATION ($) EXISTG NEW FLOOR DEMO TOTAL AREA AREA AREA NET AREA •. BATHROOM KITCHEN OTHER REMODEL AREA HO REMODEL AREA I r/ REMODEL V A PORCHAREA DECK AREA TOTAL DECKNORCH AREA GARAGE AREA: DETACH I ❑ ATTACH #DWELLING UNITS: IS A SECOND UNIT ❑YES SECOND STORY ❑YES BEINGADDED? d NO ADDITION? UNO PRE -APPLICATION ❑ YES. IF YES, PROVIDE COPY OF IS THE BLDG AN ❑ YES EIVED BV} , TOTAL VALUATION: PLANNING ADPL # ❑ NO PLANNING APPROVAL LETTER EICHLER HOME? NO By my signature below, I certify to each of the following: I am the property owner or authorilid agent to act on the property owner's behalf. fffive 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 b - ' g con&ft—cMh­-L;mthon'jc representatives of Cupertino to enter the above -identified property for inspection purposes. Signature of Applicant/Agent: Date: a^ i SUPPLEMENTAL INFORMATION REQUIRED I'CHECKT FI 3 ,. .,. I ot4il S . New SFD or Multifamily dwellings: Apply for demolition permit for QUER-THE COUNTERUIiDINGFLANREViEW q' existing building(s). Demolition permit is required prior to issuance of building permit for new building.] EFREss. ❑ ' FLANNING FLANzzEv.' Commercial Bldgs: Provide a completed Hazardous Materials Disclosure �u%sTANDA �1� PtC uSlpttrzs _ form if any Hazardous Materials are being used as part of this project.F LARGE-, { " 4Ti2EDEFT Copy of Planning Approval Letter or Meeting with Planning prior to �'r3VfAJOR © SANITARY SEySTRDJ$TRICT submittal of Building Permit application. ❑' ENVIRONMENTAL HEALTH. a ; B1dgApp 2011.doc revised 06121111