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B-2016-2397 CITY OF CUPERTINO BUILDING PERMIT BUILDINGADDRESS: CONTRACTOR: PERMIT NO:B-2016-2397 7618 SHADOWHU L IN CUPERTINO,CA 95014-5062(362 24 026) COMPLETE CONSTRUCTION EXPERTS INC SAN JOSE,CA 95129 OWNER'S NAME: DAUGHERTY WILLIAM T ET AL DATE ISSUED:07/27/2016 OWNER'S PHONE:408-930-1310 PHONE NO:(408)650-2432 LICENSED CONTRACTOR'S DECLARATION ARATION BUILDING PERMIT INFO:- License Class GENERAL BUILDING CONTRACTOR Lia#1009320 Contractor COMPLETE CONSTRUCTION EXPERTS INC Date 12/31/2017 X BLDG XELECT _PLUMB _MECH X RESIDENTIAL^COMMERCIAL I hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000)of Division 3 of the Business&Professions Code and that my license is in full force and effect. JOB DESCRIPTION: 1 ST FLOOR BATHROOM REMODEL-BATHROOM 1(40 S.F); I hereby affirm under penalty of perjury one of the following two declarations: BATHROOM 2(40 S.F.);UPGRADE PANEL(200 AMP)-SAME 1. I have and will maintain a certificate of consent to self-insure for Worker's LOCATION Compensation,as provided for by Section 3700 of the Labor Code,for the yperformance of the work for which this permit is issued. REV#1-CHANGE 2 BATHROOMS INTO 1 BATHROOM&ADD A I have and will maintain Worker's Compensation Insurance,as provided for by (N)NEW CLOSET-ISSUED 8/4/16 Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. Sq.Ft Floor Area: Valuation:$15000.00 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 to building construction,and hereby authorize 362 24 026 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 understands and will comply with all non-point source regulations per he Cupedino Municipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION. qA Signature Date 08/04/2016 Issued by: �` N �� Date: y �{ 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 intendedor offered for inspection. sale(Sec.7044,Business&Professions Code) z. '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:08/04/2016 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 MATERIALSDISCLOSURE 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(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 Cupertino Municipal Code,Chapter 9.12 and exemption,I become subject to the Worker's Compensation provisions of the the Health&Safety Code,Se ns 25505,25533,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:08/04/2016 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. 1 understand my plans shall be used as public records, Licensed Signature Date 08/04/2016 Professional i CONSTRUCTION PERMIT APPLICATION rf COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DMS • 10300 TORRE AVENUE•CUPERTINO,CA 95014-3255 r CUPERTINO (408)777-3228•FAX(408)777-3333•buildingp_cupertino.org ❑NEW CONSTRUCTION [:1ADDITION ❑ ALTERATION/TI `REVISION DEFERRED ORIGINAL PERMIT# 0 PROJECT ADDRESS � �Q� LVJ OWNER NAME Q `,1 �tl 1` PHONES(i�,/pe�i� E-MAIL. . STREET ADDRESS ) bJ CITY,STATE,ZIP '� J e 1 FAX CONTACT NAME � � _ ,5�. PI�.�� � TE-MAH, STREET ADDRESS CITY,QSTATE, IP FAX 5 os r., 4 El OWNER ❑ OWNER-BUILDER ❑ OWNERAGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT `U, ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME LICENSE NUMBER LICENSE TYPE BUS.LIC# COMPANY NAME E-MAIL " STREET ADDRBSS 4� �AW 7 CITY,��1T�^p g �� �/(� PHONE Qi 14 Y ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC# COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE DESCRIPTION OF WORK ks 0 Re S bA"kln 1 EXISTING USE PROPOSED USE - CONSTR-TYPE #STORIES - - - - USE TYPE OCC. SQ.FT. VALUATION($) EXISTG NEW FLOOR DEMO TOTAL AREA AREA AREA. NET AREA i 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? ❑NO ADDITION? [3NO - PRE-APPLICATION ❑YES IF YES,PROVIDE COPY OF IS THE BLDG AN - - TOTAL VALUATION: PLANNINGAPPL# FIND PLANNING APPROVAL LETTER EICHLER HOME'S N - - By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on the owner's behalf. I have read this application and the information I have providedorrect. I have read the Description of Wark and verify it i ate. 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-den ed property for inspection purposes. Signature ofApplicanbAgent: �' Date: SUPPLEMENT INFORMATION REQUIRED " w RDI7TING SLAP PLAN CIiFCI TYPE _New SFD or Multifamily dwellings: Apply for demolition permit-for ❑ ovER THE- QU]N i ] B1ITLDI4PLAN R aw existing building(s). Demolition permit is required prior to issuance of building permit for new building. L7 PRESS PLAxiN rvL� _Commercial Bldgs: Provide a completed Hazardous Materials Disclosure ❑ $TANDARn ❑ suaircwoits form if any Hazardous Materials are being used as part of this project. T?ARGE � FII2TDEPT;. _Copy of Planning Approval Letter or Meeting with Planning prior to SEwERDISTRICT submittal of Bulling Permit application. rx SANITa1RY ENViRONMENTALHEAZTH B1dgApp_2011.doc revised 06/21/11 M CITY OF CUPERTINO BUILDING PERMIT BUILDINGADDRESS: CONTRACTOR: PERMIT NO:B-2016-2397 7618 SHADOWHIL L IN CUPERTINO,CA 95014-5062(362 24 025) COMPLETE CONSTRUCTION EXPERTS INC SAN JOSE,CA 95129 OWNER'S NAME: DAUGHERTY WILLIAM T ET AL DATE ISSUED;07/27/2016 OWNER'S PHONE:408-823-9612 PHONE NO:(408)650-2432 LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: License Class GENERAL BUILDING CONTRACTOR Lic.#1009320 BLDG 3f ELECT _PLUIVFH Contractor COMPLETE CONSTRUCTION EXPERTS INC Date 1211 J2017 I hereby affirm thatI 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: 1 ST FLOOR BATHROOM REMODEL-BATHROOM 1(40 S.1?.); I hereby affirm under penalty of perjury one of the following two declarations: BATHROOM 2(40 S.F.),UPGRADE PANEL(200 AMP);SAME x. I have and will maintain a certificate of consent to self-insure for Worker's LOCATION j Compensation,as provided for by Section 3700 of the Labor Code,for the S*performance of the work for which this permit is issued. z, 1 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 permitis issued. Sq.Ft FloorAraa: Valuation;$15000.00 APPLICANT CERTIVICATION I certify that I have read this application and state that the above information APN Number: Occupancy y TyPe is correct.I agree to comply with all city and county ordinances and state laws relating to building construction,and hereby authorize 362 24 026 representatives of this city to enter upon the above mentioned property for Inspection purposes. (Vile)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 accrueagai t said City inconsequence of the granting of this permit. WITHIN 180 DAY;; OF PERMIT ISSUANCE OR Additionally,�t ap icant understands and will comply with all non-point source regulations p r the qupertino Municipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION. Signature Z Date 712V2016 Issued by:Abby Aygnde Date:07/27/2016 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 i i. 1,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 o€Applicant: contractors to construct the project(Sce.7044,Business&Professions Code). Date:7j.27/2016 I hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER x. 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 z. 1 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 maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the permit is issued. Health&Safety Code,Section 25532(x)should I store or handle hazardous a. I certify that in the performance of the work for which flys permit is issued,I 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 jay-A Air Quality Management District I Worker's Compensation laws of California. If,after making this certificate of will maintain Compliance with "ug'..- Municipal Code,Chapter 9.12 and exemption,I become subject to the Worker's Compensation provisions of the the Health&Safety de,Sectio s 503-2Srs-11,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:7/27 2 1 certify that t 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 its 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(See.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, tender's Address judgments,costs,and expenses which may accrue against said City in consequence of the granting of this permit. Additionally,the applicant understands ARCHITECT'S DECLARATION and will comply with all non-point source regulations per the Cupertino Municipal I understand my plans shall be used as public records. Code,Section 9.18. Licensed Signature Date 7/27/2016 Professional I i CONSTRUCTION PERMIT APPLICATION its COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO,CA 95014-3255 CUP1EltT1NQ (408)777-3228•FAX(408)777-3333•builclinaacupertino.Dfg NEW CONSTRUCTION Q ADDITION ALTERATION/TI t_d REVISION I DEFERRED ORIGINAL PERMIT# PROJECTADDRESS + APN# 1 —11.91 OWNER NAME �' fn •?S � t / PHONE /_O d)��.y J� CI E-MAIL STREETADDRESS CITY, TATE,ZIP :LAX C- CONTACT NAME ( —_ _'k - - PHON ./ r E-MAIL s ✓l.!e,t }�Yy till F1 ' �' .L12tA-; STREET ADDRESSZIP f �y FAX E} dF ('3 j] S� ` 13 OWNER 1 OWNER-BUILDER ®OWNERAGENT CONTRACTOR gCONTRA.CTOR AGEur El ARCHITECT 11 ENGINEER © DEVELOPER 13 TENANT NTRACrORN ME '/' �iC&5NUMBER LICENSEBUS.LIC# JIM') c 6 .$C-,-, COMPANYNAME - E- ,yr°� p FAX a a /:t hat ti c L d je 6•.s,a Mc�Azs '�-` B�k,4 J . S '6'7'ADllREas CITY,STATE,ZIP. PRONE ARCIETECVLNGEMERNAME IdCENSE NUMBER BUS.LIC# COMPANY NAME - E-MAIL - FAX STREET ADDRESS - CITY,STATE,ZIP - PHONE I DESCRIPTION OF WORK ctrS1 a v.e�e � Yti 8 `a5 �� F i`t5ar is I EXISTING USE PROPOSED USE -- DONST'R.TYPE #STORIES -- I35I3 'TYPE OCC. SQTT- VALUATION($) EXISTG NEW FLOOR DEMO TOTAL AREA_ AREA AREA NETAREA BATHROOM KITCHEN OTHER - - REM.ODELAREA.1 REMODEL.AREA •REMODELAREA i •. PORCHAREA I DECKAREA TOTAL DECK/FORCH AREA GARAGEAREA: DETACH - - ®ATTACH #DWELUNGUNITS: ONDD 1T © SECON STORY YS BEING A � OEIE PRE-APPLICATION YES IF YES,PROVIDE COPY OF ISTHEBLDGAN ®YES BY. TO VAL ATIW: PLANNINOAPPL# 13NO PLANNING APPROVAL LETTER ETCHLER HOME? 13 NO By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on t e property owner's behalf. I have read this application and the information I have provi nett. 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 g cans ciion I authorize representatives of Cupertino to cater the above-identifi d propetty for inspectiolr purposes. Signature of ApplicantlAgent: Date: _ SUPPLEMENTAL.INFORMA I N 12EQUIRED PLAN CHECK TYPE ROOTING S13P i Neov SFD or Multifamily dtivellings: Apply for demolition permit for D OVER-THE-COUNTER EI BUILDING PLAN REvirw existing building(s). Demolition permit is required prior to issuance of building permit for new building. 11 EXPRESS ❑ PLANNING PLAN REVMW _Commercial Bldgs: Provide a completed.Hazardous Materials Disclosure ❑ STANDARD 11 PUBLIC WORxS farm if any Hazardous Materials are being used as part of this project. ❑ LARGE ❑ FUM DEPT Copy of Planning Approval Letter or Meeting with Planning prior to MAJOR ❑ SANITARY SEIYER DISTRICT sBhrnittal of Building Permit application. ❑ ENVIRONMENTAL HRA LTH -aldgApp_2011.doe retdfsed 06121/11 Ii