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B-2016-2342CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: CONTRACTOR: PERMIT NO: B-2016-2342 21757 MCCLELLAN RD CUPERTINO, CA 95014-4053 (357 19 062) ADRIAN FOLEY CONSTRUCTION COSTA MESA, CA 92626 OWNER'S NAME: TRISNADI JAHJA I AND KRISTINA W TRUSTEE DATE ISSUED: 07/19/2016 OWNER'S PHONE: 408-390-4719 PHONE NO: (714)200-1512 LICENSED C )ECLARATION BUILDING PERMIT INFO: License Class B Lie, #736776 Contractor ADRIAN FOLEY CONSTRUCTION Date 06/30/2019 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: REPLACE 10 WINDOWS (LIKE FOR LIKE) - 2 BEDROOMS; 2 1 hereby affirm under penalty of perjury one of the following two declarations: KITCHEN; 2 FAMILY ROOM; 2 STAIR WELL; 2 BATHROOMS 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, have and will maintain Worker's. Compensation Insurance, as provided for by y A2�--1 Section 3700 of the Labor Code, for the performance of the work for which this Sq. Ft Floor Area: Valuation: $10000.00 permit is issued. 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 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 applicant understand and will comply with all non -point source regulationsyer the Cup rt no Municipal Code, Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION. Signature _ ,_� r Date 7/19/2016 Issued by: Abby Ayende Date 07/19/2016 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 roof -mg 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 ofApplicant: contractors to construct the project (Sec.7044, Business & Professions Code). Date:197/ /2016 l 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 3. I certify that in the performance of the work for which this permit is issued, I Health & Safety Code, Section 25532(x) 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 Code, Sections 25505, 25 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: 7/19/2016 I certify that I have read this application and state that the above information is CONSTRUCTION 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. I understand my plans shall be used as public records. Licensed Signature Date 7/19/2016 Professional CUP RTIN CONSTRUCTION PERMIT APPLICATION 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 �1d+�jORIGINAL PERMIT # PROJECT ADDRESSJ v 1GI G" o APN # 5 - 4 V OWNER N _cam Lt 4'� 9r i � i v/l�i 1 i %)�L�C� P O l7 a) 36-0 '- 0-7 t� E-MAIL FAX STREET ADDRESS CI�Ty, STATE, ZIP ztA I V1 �CIi Cr ii1 C e � ✓tJ q-0; 41�® CONTACT N PHONE E-MAIL STREET ADDRESS CITY, STATE, ZIP FAX 6 7 7 0 -04 `3 �i iV 1`ee C' F ��`�`� OWNER ❑ OwNER-BUIIAER ❑ OWNER AGENT .❑ CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR N / LICE NUMBER LICENSE TYPE BUS. LIC # t c> IT .iCAWY, 3 C,i 76- �3� ;n B` COMPPY N MAI q, E -L t (_ FAX +' �+itt KJillW l �C� C�i— C STREET ADDRESS CITY, STATE, ZIP PHONE ARCHITECT/g\ INEER NAME LICENSE R BUS. IC # COMPANY NAME E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP \ PHONE DESCRIPTION OF qC EXISTING USE PROPOSED USE CONSTR. TYPE - # STORIES USE TYPE OCC. SQ.FT. VALUATION {$} EXISTG NEW FLOOR DEMO TOTAL AREA AREA AREA NETAREA BATHROOM KITCHEN OTHER - REMODEL AREA REMODEL AREA REMODEL AREA.. - PORCH AREA DECK AREA TOTAL DECK/PORCH AREA GARAGE AREA: DETACH - ❑ATTACH #DWELLING UNITS: ISA SECOND UNIT ❑YES SECONDSTORY []YES BEING ADDED? []NO ADDITION? ❑ NO PRE -APPLICATION ❑ YES IF YES, PROVIDE COPY OF IS THE BLDG AN ❑ YES REC . F-DBY:TOTALVALUATION: OD PLANNING APPL # ❑ NO PLANNING APPROVAL LETTER EICHLER HOME? ❑ NO 1M gc. By my signature below, I certify to each of the following: I am the property owner or authorized agent to a t on the p operty 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 relating to build' 1econstruc� n. I autho ' e representatives of Cupertino to enter the above -identified property for inspection purposes. Signature of Applicant/ADate: ( l SUPPLEMENTAL INFORMATION REQUIRED PLAN CIiECK T YFE xozrruvc stir _ New SFD or Multifamily dwellings: Apply for demolition permit for vF r OYER THL COUNT t © BUILDING PLANBT}Nj W existing building(s). Demolition permit is required prior to issuance of building F permit for new building. ❑ANNGx ANizEEw .� Commercial Bldgs: Provide a completed Hazardous Materials Disclosure ��STANDARD w' ❑ PUBLICwfl form if any Hazardous Materials are being used as part of this project. ` LA>zci` _ Copy of Planning Approval Letter or Meeting with Planning prior to L7;InrArorz [] sNrrAxY SEWERDT5112iCT submittal of Building Permit application. ENVIRpNMBNTALHEALTH BldgApp_2011.doc revised 06121111 RECEIVED J lu, L I0 -%- CLOSET CLOSET 1;L-757 -w4lvv UT 5X6 DEVELOPMEM I MMENT 1G DIViSION - CUPERTINO APP ROVED Mr, t o 61 ins and specifications MUST be kept at the c0ilstrtictiOn- It is unlawful to make any U" alterations on same, or to deviate t approval from the Building Official. is plan and specifications SHALL NOT or to bo W' approval of the Violation Of al.NY city Ordinance 48 *4 24Y7 10X5 (P� 40? DATE -4-41 C IF Ft G -f icCw-, P5LAI NTNG D IG DEPT CUPERTINO M 31 low p �j 3 P MIT Lip GARAGE 4 y � y l f 7 ° 3 �t t 6 4 e t i 24 tr 9 x 16 15 i P a x I 12 16