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12110062 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 22311 STEVENS CREEK BLVD CONTRACTOR:DMD GENERAL PERMIT NO: 12110062 CONSTRUCTION OWNER'S NAME: BEN-ASHER MOR/CHEN 4319 RENAISSANCE DR APT305 DATE ISSUED: 12/19/2012 OWNER'S PHONE:.4089664972 SAN JOSE,CA 95134 PHONE NO:(408)373-2911 ❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTM, COMMERCIAL 11 License Class .B Lic.# �S CONSTRUCT ONE STORY ADDI'T'IONS(617 SQ FT); Trr L CQIX�ir°Date INTkRIOR REMODEL,(300+/-SQ FT);REMOVE AND Contractor + ir11 � Z©�3 REPLACE EXISTING ROOF STRUCTURE(992 SQ FT); I hereby affirm that I am,licensed under the provisions of Chapter 9 ; (commencing with Section 7000)of Division 3 of the Business&Professions VISINI-STRUCTURAL CHANGES-ISSD OTC 1/30/2013 Code and that my license is in full force and effect. s' I hereby affirm under penalty of perjury one of the following two declar ns: I have and will maintain a certificate of consent to self-insure for Worker' Compensation,as provided for by Section 3700 of the Labor Code,for,, performance of the work for which this permit is issued. Sq.Ft Floor Area: Valuation:$100000 1 have and will maintain Worker's Compensation Insurance,as pr ded f Section 3700 of the Labor Code,for the performance of the wor' or w APN Number:32650036.00 Occupancy Type: permit is issued. APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED correct.I agree to comply with all city and county ordinances and state laws relating WITHIN 180 DAYS OF PERMIT ISSUANCE OR building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We)agree to save180 DA ®M LAST CALLED INSPECTION. indemnify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City in consequence of the granting of this permit. Additionally,the applicant understands and will comply Issued by: Date: with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. RE-ROOFS: Sign eAll roofs shall be inspected prior to any roofing material being installed.If a roof is installed without first obtaining an inspection,I agree to remove all new materials for inspection. OWNER-BUILDER DECLARATION Signature of Applicant: Date: I hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER 1,as owner of the property,or my employees with wages as their sole compensation, will do the work,and the structure is not intended or offered for sale(Sec.7044, Business&Professions Code) 1,as owner of the property,am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE construct the project(Sec.7044,Business&Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the California Health&Safety Code,Sections 25505,25533,and 25534. 1 will I hereby affirm under penaltyof perjury one of the following three maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the declarations: Health&Safety Code,Section 25532(a)should I store or handle hazardous have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally,should R use equipment or devices which emit hazardous Compensation,as provided for by Section 3700 of the Labor Code,for the air contaminants as defined by the Bay Area Air Quality Management District I performance of the work for which this permit is issued. will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sections 25505,25533,and 25534. Section 3700 of the Labor Code,for the performance of the work for which this � Owner or authorized ag Date:_0 r permit is issued. I certify that in the performance of the work for which this permit is issued,I shall not employ any person in any manner so as to become subject to the Worker's Compensation laws of California. If,after making this certificate of exemption,I CONSTRUCTION LENDING AGENCY become subject to the Worker's Compensation provisions of the Labor Code,I must I hereby affirm that there is a construction lending agency for the performance of forthwith comply with such provisions or this permit shall be deemed revoked. work's for which this permit is issued(Sec.3097,Civ C.) Lender's Name APPLICANT CERTIFICATION Lender's Address 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 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 ARCHITECT'S DECLARATION indemnify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records. granting of this permit.Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code,Section Licensed Professional 9.18. Signature Date CITY OF CUP ER'I(INO BUILDING PERMIT BUILDING ADDRESS: 22311 STEVENS CREEK BLVD CONTRACTOR: PERMIT NO: 12110062 OWNER'S NAME: BEN-ASHER MOR/CHEN ( 15-eV),?40 W 1( A�_ DATE ISSUED: 12/19/2012 OWNER'S PHONE: 4089664972 PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATION ]BUILDING]PERMIT INFO: ]BLDG F ELECT F PLUMB F License Class Lic.# `ry f� g MECIIII F IBESIDENTL4L F COMMERCIAL I— Conti r Dat /Q V1,01 i? 1 her affirm that I am licensed under the provisions of Chapter 9 JOB DESCEU PTION:CONSTRUCT ONE STORY ADDITIONS(617 SQ FT); (co mencing with Section 7000)of Division 3 of the Business&i Professions INTERIOR REMODEL(300+/-SQ FT);REMOVE AND Code and that my license is in full force and effect. REPLACE EXISTING ROOF STRUCTURE(992 SQ FT); 1 hereby affirm under penalty of perjury one of the following two declarations: I have and wilt 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 Labor Code,for the performance of the work for which this Sq.Ft Floor Area: Valuation:$100000 permit is issued. APPLICANT CERTIFICATION APN Number:32650036.00 Occupancy Type: 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 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 PERM1 7 EXPIRES IF WORK IS NOT S7ART ED indemnify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City in consequence of the WITHIN 180 DAYS OF PERMIT ISSUANCE OR granting of this permit. Additionally,the applicant understands and will comply 180 DAYS FROM LAST CALLED INSPECTION. ON. with 611 non-point source regulations per the Cupertino Municipal Code,Section 9.18. Signat Date Wj'Y1201? Issued by: Date:fG'`f� l ❑ OWNER-BUILDER DECLARATION RE-ROOFS: 1 hereby affirm that I am exempt from the Contractor's License Law for one of All roofs shall be inspected prior to any roofing material being installed.If a roof is the following two reasons: installed without first obtaining an inspection,I agree to remove all new materials for 1,as owner of the property,or my employees with wages as their sole compensation, inspection. will do the work,and the structure is not intended or offered for sale(Sec.7044, Business&Professions Code) Signature of Applicant: Date: I,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044,Business&Professions Code). ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER I hereby affirm under penalty of perjury one of the following three declarations: HAZARDOUS MATERIALS DISCLOSURE 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 I have read the hazardous materials requirements under Chapter 6.95 of the performance of the work for which this permit is issued. California Health&r Safety Code,Sections 25505,25533,and 25534. I will maintain 1 have and will maintain Worker's Compensation Insurance,as provided for by compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&c Section 3700 of the Labor Code,for the performance of the work for which this Safety Code,Section 25532(a)should I store or handle hazardous material. Additionally,should I use equipment or devices which emit hazardous air permit is issued. contaminants as defined by the Bay Area Air Quality Management District I will I certify that in the performance of the work for which this permit is issued,I shall maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the not employ any person in any manner so as to become subject to the Worker's Health&z Safety Code,Sections 25505,25533,and 25534. Compensation laws of California. If,after making this certificate of exemption,l become subject to the.Worker's Compensation provisions of the Labor Code,I mus horized a en forthwith comply with such provisions or this permit shall be deemed revoked. Date: CONSTRUCTION LENDING AGENCY APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is I hereby affirm that there is a construction lending agency for the performance of work's correct.I agree to comply with all city and county ordinances and state laws relating for which this permit is issued(Sec.3097,Civ C.) to building construction,and hereby authorize representatives of this city to enter Lender's Name upon the above mentioned property for inspection purposes.(We)agree to save indemnify and keep harmless the City of Cupertino against liabilities,judgments, Lender's Address costs,and expenses which may accrue against said City in consequence of the granting of this permit.Additionally,the applicant understands and will comply ARCHITECT'S DECLARATION with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. 1 understand my plans shall be used as public records. Signature Date Licensed Professional 2l 62- CONSTRUCTION PERMIT APPLICAT�Ohll COMMUNITY DEVELOPMENT DEPARTMENT< BUILDING DIVISION 10300 TORRE AVENUE^CUPERTINO, CA 95014-3255 CY,JPERTIINO (408) 777-3228^ FAX(408) 777-3333^building(a-cupertino.org ❑NEW CONSTRUCTION ADDITION ❑ ALTERATION/TI n❑ REVISION/DEFERRED ORIGINAL PERMIT# PROJECT ADDRESS �`� l (r`QIf APN# 3&5o t� ' OWNER NAME i1,!� � � f� PHONE 1/D� �/ ��/,-(� E-MAIL STREET ADDRESS CITY,STATE,ZIP q So`Ll FAX CONTACT NAME I _ PHONE �D /]�/ 1, � E-MAIL (, o r v 10if, STREET ADDRESS CITY,STATE, ZIP FAX I1OWNER ❑ OWNER-BUILDER ❑ CANER AGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT '.. CONTRACTOR NAME LICENSE NUMBER LICENSE TYPE BUS.LIC# COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE ARCHITECT/ENGiNEEnR NAME ` a LICENSE NUMBER BUS.LIC# COMPANY NAME EMAIL �Q I n/ FAX STREET ADDRESS 1� CITY,STATE,ZIP /� �G l PHONE DESCRIPTION OF WORK U J` (�a1tglj EXISTING USE PROPOSED USECONSTR..T E STO S I USE TYPE OCC. SQ.FT. VALUATION(S) EXISTG- // r] NEW FLOOR DEMO TOTAL AREA AREA y Got o / AREA NET AREA G v 1 BATHROOM yy�� KITCHEN OTHER REMODEL AREA ter REMODEL AREA � REMODEL AREA 4 .APE PORCH AREA DECK AREA TOTAL DECKIORCH AREA GARAGE AREA: ?I ETACH ��� �I ATTACH #DWELLING UMTS: IS A SECON-D UNIT DYES SECOND STORY El YES BEING ADDED? F�9Q0 ADDITION? IB,16 PRE-APPLICATION ❑l IF YES,PROVIDE COPY OF IS THE BLDG AN ❑YES .RECEIVED BY n x„ t i1 TOTAL VALUATION: PLANT G APPL# JO PLANNING APPROVAL LEITER EICHLER HOnLE? �"t�0 ,+�'y f�.� x " / ®� 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 ha a read this application and the information III p v'ded 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 Pi o const/ tion. I th sentatives of Cupertino to enter the abode;�e tified property for inspection purposes. Signature of Applicant/Agent: Date: ����yyff 0 SUPPLEMENTAL INFO ION REQUIRED PccrxarE ,f.,-.ItoUTNcsLiP New SFD or Multifamily dwellings: Apply for demolition permit for ❑ OVER.THE CovNTER BITILDIAGPLAN REVLE\y existing building(s). Demolition permit is required prior to issuance of building permit for new building. t:❑ E IiEss a Il7tPLAT'MNGrinxREVIEw _Commercial Bldgs: Provide a completed Hazardous Materials Disclosure csTANDARD PUBL>Gw oRLs form if any Hazardous Materials are being used as part of this project. :❑ LARGE ❑ FIREnEPT _Copy of Planning Approval Letter or Meeting with Planning prior to submittal of Building Permit application. ❑;nlnSoR } SANITARY SERERDISTRICT 0 ENV1RONA ENTALHtALTH BldgApp_2011.doc revised 06121111 COMMUNITY DEVELOPMENT DEPARTMENT-BUILDING DIVISION 10300 TORRE AVENUE^CUPERTINO, CA 95014-3255 CUPERTINO (408)777-3228 o FAX(408)777-3333^buildin cu ertino.or I gl 16 [:]NEW CONSTRUCTION ADDITION ❑ ALTERATION/Tl REVISION/DEFERRED ORIGINAL PERMIT# PROJECT ADDRESS 36 5�e J �a� �LV APN# �� /_ '5D / OWNER NAME C PHONE E-MAIL STREET ADDRESS CITY,STATE,ZIP FAX StFps li 6TAI Cd9- '?a0! CONTACT NAME .A �. �7 PHONE. oe 3�_3��tD E-MAIL STREETADDRESSA/! .d„Osn ,�./ CITY,S ATE, ZIP FAX ❑ OWNER ❑ OWNER-BUILDER °❑ OWNERAGENT WCONTRACTOR ❑CONTRACTOR AGENT ❑. ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME /_ p f Q , LICENSE NUMIL �(BER n�,, DENSE[YPE BUS.LIC# COMPANY N ME -MA (+ FAX � CoVsi —,)6 STREET ADORES C ,S ATE,ZIP PHONE e9''�3 mil ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC# COMPANY NAME E-MAIL FAX STREET.ADDRESS CITY,STATE,ZIP PHONE DESCRIPTION OF WORK C Cet-WCPJ EXISTING USE PROPOSED USE CONSTR.TYPE I STORIES USE TYPE OCC. SQ.FT. VALUATION($) EXISTG NEW FLOOR DEMO TOTAL AREA AREA AREA NET AREA BATHROOM KITCHEN OTHER REMODEL AREA REMODEL AREA REMODEL AREA PORCH AREA DECK AREA TOTAL DECK/PORCH AREA GARAGE AREA: DETACH ❑ATTACH #DWELLING UNITS: IS A SECOND UNIT ❑YES SECOND STORY []YES BEING ADDED? Cl NO ADDITION? NO '....... PRE-APPLICATION ❑YES IF YES,PROVIDE COPY OF IS THE BLDG AN ❑YES RECEIVED T' UATION: PLANNING APPL# []NO PLANNING APPROVAL LETTER EICHLER HOME? ❑NO 1 Y� a. By my signature below,I certify to each of the following: 1 am the property owner or au orizedafintA 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 applicable local ordinances and state laws relating to building construction. I authorize representatives of Cupertino to enter the above-identified property for inspection purposes. Signature of Applicant/ Date: 2? o t SUPPLE TAL INFORMATION REQUIRED �PLANfCHECKIYPE' A R6t9TINGSLIP, New SFD orivrultifamily dwellings: Apply for demolition permit for ovER TIiFCouNTI R ttH nnvG PIAN REVIEW existing building(s). Demolition permit is required prior to issuance of building ,�. ' ❑ PI ANNING PLAN REVIEW permit for new building. ,Cl: EXPRESs _Commercial Bldgs: Provide a completed Hazardous Materials Disclosure ❑e�STANDARD ❑ 'PUBLIC WORKS form if any Hazardous Materials are being used as part of this project, ❑'� LARGE- ❑rFIRE DEPT Copy of Planning Approval Letter or Meeting with Planning prior to submittal Of Building Permit application. MAJOR., ❑ `sANITARY'SEWERDiSTRICT' c ❑ ENVIRON MENTAL HEALTH BldgApp_2011.doc revised 06/21/11 Building Depa7tme_rll City Of Cupertino 10300 Torre Avenue Cupertino,CA 95014-3255 Telephone,405-777-3225 CUPERTI N0 Fax 408-777-3333 CONTRACTOR/ SUBCONTRACTOR ILRST JOB ADDRESS '' !, �;-, <' ' �3 « PERMIT# OWNER'S NAME: il.' ✓' PHONE# GENERAL CONTRACTOR:' BUSINESS LICENSE# ADDRESS: tj p ) ^;• ; 2i CITY/ZIPCODE: *Our municipal code requires alll businesses working in the city to Cnaive a CML ©� C;:L,,,ertlno trr�����ess Guae�se, NO BUILDING FINAL OR FINAL OCCUPANCY dNSPEC'11'UN(51 VA' LL 31E SCHEMI" ED, UN GENERAL CONTRACTOR AND ALLSUBC®NTRACMRS HAVE UB7A'iI,�IED A CST~t 0'1,1C�J��� BUSINESS LICENSIE. I am not using any subcontractors: - Signatur¢ IDate Please check applicable subcontractors and compEete the ffoliowmg SUBCONTRACTOR BUMNESS NAME 3 U S NESS LE,C EN, 57, „! Cabinets&Millwork Cement Finishing ---- --_ Electrical Excavation , -,_ Fencing _ - --- - - -- — - Flooring/Carpeting i , -------- Linoleum/Wood - Glass/Glazing r - v Heating Insulation Landscaping Lathing 7r^,c:) Masonry Painting/Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile ' Owner/Contractor Signature Date