B-2016-2172CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS:
CONTRACTOR:
mm
r NO: B-2016-2172
20400 STEVENS CREEK BLVD CUPERTINO, CA 95014 (369 01 028)
CODY/BROCK INC
SAN CARLO:S, CA
94070
OWNER'S NAME: CUPERTINO CITY CI;XMRBUR DINGS
DATE
SUED: 06/21/2016
OWNER'S PHONE: 408-873-0121
PHONE
O: (650) 591-0757
LICENSED CONTRACTOR'S DECLARATION
BUILDING PERMIT INFO:
License Glass 8 Lic. #D339TI.
Contractor CODY/BROOK INC Date 04/30/2018
.
X BLDG — ELECT _.PLUT
1B
M ECH
COMMERC IAIL
I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing
_ _RESIDENTIAL
with Section 7000) of Division 3 of the Business & Professions Code and that my
license is in Full force and effect..
JOB DESCRIPTION:
4TH FLOOR-T.I. PREP (579!.S.F.)
I •hereby affirm under penalty of perjury one of the following two declarations:
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.
2�1 have and will maintain Worker's Compensation Insurance, as provided for jy
ZSeetion 3700 of the Labor Code, for the performance of the work for which this
'
permit is issued.
Sq.FtFloor Area, Valuati
n:$3450.00.04
AUILCANT CERTIFICATION
I certify that .I have read this application and state that the above
Number:
Occup
ey Type:.
information is correct. I agree to comply with all city and county ordinances
369 OI 028
3 69
A (Ton
t Improvements)
and state laws relating to building construction, and hereby authorize
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 EXPIRESWORD
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 understands and will comply with all non -point
source regulations per the Cupertino Municipal Code, Section 0.18..
180 DAYS FROM. I,
ST CALLED
INSPECTION.
S:ignature a^ ti Date 1i2
Issued by: AbbyAy_ende
Date: 06/21/2016
ER -B DER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of the.
All roofs shall be inspected prior "
any roofing material
being installed. If a roof is
following two reasons:
installed without first obtaining an
inspection, I agree to r
move all new materials for
i. I, as owner of theproperty, or my employees with wages as their sole
inspection:
compensation; will . o the work, and the structure is not intended or offered for
d
sale (Sce,7044, Business & Professions Code)
2. 1, as owner of the property, am exclusively contracting with licensed
Signature of Applicant:
contractors to construct the project (Sec.7044, Business .& Professions Code).
Date: " .612112016
I hereby affiraa ander penalty of perjury one of the following three declarations:
ALL ROOF,COVERIl
S TO BE CLASS "
'" OR BETTER _
-
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
HA LZARDOUS
M.ATERIALSDISCDISCk OSURE
performance ofthe work for which this permit is issued.
I have read the hazardous mat
rials requirements u . der, Chapter 6.95 of the
2. I have and will maintain Worker's compensation insurance, as provided for by
California Health & Safety C
de,. Sections 25505, 5533, and 25534. I will'
Section 3700 of the Labor Code, for the performance of the work for which this
maintain compliance with the C
pertino Municipal C ode, Chapter 9.12 and the
permit is issued.
Health & Safety Code, Sectio
25532(a) should I st re or handle hazardous
& 1 certify that in the performance of the work for which this permit is issued, I
material. Additionally, should I
ise equipment ord6v ces which emit hazardous
Shall not employ any person in any manner so as to become subject to theair
contaminants as defined by t
e Bay Area Air Qu. ty Management District I
Worker's Compensation laws of California. If after making this certificate of
will maintain compliance with t1
e Cupertino Municip -d Code, Chapter 9.12 and
exemption, I become subject to the worker's Compensation provisions of the
the health & Safety C
de, Sections 25505, 2 5533, and 25534.
Labor Code, I must forthwith comply with such provisions or this permit shall
�
be deemed revoked.
• �
0 Qr or authorized agent:
Date: !2 /2
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is
N T
1 hereby affirm that there is co
ON LEND E
struction lending a envy for the performance
correct. I agree to comply with ali city, and county ordinances and state laws
of work's for which this permit i
issued (Sec. 3097, iv C.)
relating to building construction, and hereby authorize representatives of this .city
Lender's Name
to enter upon the above mentioned .property for inspection purposes. (We) agree
to save indemnify and keep harmless the City of Cupertino against liabilities,
Lender's Address
judgments, costs, and expenses which may accrue against said City in
of the of this permit. Additionally, the applicant understands
, DE
consequence granting
and will comply with all non -point source regulations per the Cupertino Municipal
ARC
I understand My plans shall be
sed as public recur. S.
Code, Section 9.18.
Licensed
Signature Date 6 1/2016
Professional
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT BUILDING DIVISION
10300 TORRE AVENUE • CUPERTIN O, CA 95014-3255
U P EhTMO (408) 777-3228 • FAX (408) 777-3333 - :buiidingA.Cupeltino.ot g iGINAL PERMIT
® NEW CONSTRUCTION F1 ADDITION ALTERATION / TI F1 REVISION / DEFERRED
PROTECT ADDRESS
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APN #
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OWNERNAME
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DESCRIPTION OF WORK
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EXISTING USE
PROPOSED USE
CONSTR. TYPE
#STORIES
USE
TYPE
CC.
SQ•FP.
VALUATION ($)
O t tL
O Gi✓ SP/ -E
EXISTG NEW FLOOR DEMO TOTAL
. AREF `�., �1 AREA AREA NET ARE
HA'tHROOM — - KrfCHEN - - - OTHER
REMODELAREA REMODELAREA REMODELAREA
PORCH AREA
DECK AREA
- TOTAL DECK/PORCH AREA
GARAGE AREA: DETACH:
❑ATTA.CH
- #DWELLINGUNLTS: ISASECOND.UNIT ❑.YES SECONDSTORY ❑YES
BEINGADDED? - ❑NO ADDMON? ®NO
` PRE -APPLICATION []YES IF YES, PROVIDE COPY OF IS THE BLDG AN ❑ YES' - TOTAL V UATION:
NO H }"��
PLANNINGAPPL#i ❑NO PLANNING APPROVAL LETTER EICHLERHOME? [3 . -
By my signature below, I certify to each of the following: I am the property owner or authorized agent to act A the property owner's behalf. I hav read this
application and the information I have provided is correct. I have read the. Description of Work:and verify it is accurate. I a e to comply with all : plilocal
" 'on
ur
ordinances and state laws relating to building construction- I authorize representatives of Cupertino to enter the above -idea ed property for' purposes.
Date G1z!
Signature of Applicant/Agent:
SUPPLEMENTAL INFORMATION REQUIRED M�
_ New SFD or Multifamily dwellings: Apply for demolition permit for PR
existing building(s). Demolition permit is required prior to issuance of building
for building;
permit new ti �
Materials Disclosure
Commercial Bldgs; Provide a completed Hazardous
_
form if any Hazardous Materials are being used as part of this project.�tG
_ Copy of Planning Approval Letter or Meeting with Planning prior to -
submittal of Building Permit application.
IWdg,4pp 2011-doI revised 06121111