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B-2016-2450 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: CONTRACTOR_ : PERMIT NO:B-2016-2450 10481 JOHNSON AVE CUPERTINO,CA 95014-3862(375 17 047) DELSUR CONSTRUCTION ENTERPRISES SOUTH SAN FRANCISCO,CA 94083 OWNER'S NAME: KUSHNERANNEDORE DATE ISSUED:08/03/2016 OWNER'S PHONE:650-450-8009 PHONE NO:(415)305-7638 LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: License Class B Lic.# 32951 Contractor DELSUR CONSTRUCTION ENTERPRISES Date 05/31/2017 X BLDG X ELECT PLUMB I hereby affirm that I am licensed under the provisions of Chapter 9(commencing —MECH X RESIDENTIAL_COMMERCIIAL 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-E,M,P(45 S.F.);UPGRADE I hereby affirm under penalty of perjury one of the following two declarations: PANEL(200 AMP);SAME LOCATION;CONSTRUCT POCKET DOOR i. I have and will maintain a certificate of consent to self-insure for Worker's BETWEEN BATHROOM AND BEDROOM 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 permit is issued. Sq.Ft Floor Area:. Valuation:$18000.00 APPLICANT CERTIFICATION certify that f have read this application and state that the above information is correct.I agree to comply with all city and county ordinances APN Number: Occupancy Type: and state laws relating to building construction,and hereby authorize 375 17 047 representatives of this city to enter upon the above mentioned property for inspection purposes. (We)agree to save indemnify and keep harmless the City of Cupertino against liabilities,judgments,costs,and expenses which PERMIT EXPIRES IF WORK IS NOT STARTED may accrue against said City in consequence of the granting all this permit. WITHIN 180 DAYS OF PERMIT ISSUANCE OR Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION. Signature Date B/3/2016 Issued by:Abby ev nde Date:08/03/2016 I hereby affirm that I am exempt from the Contractor's License Law for one of the RE-ROOFS: following two reasons: All roofs shall be inspected prior-to any roofing material being installed.If a roof is 1. I,as owner of the property,or my employees with wages as their sole installed without first obtaining an inspection,I agree to remove all new materials for compensation,will do the work,and the structure is not intended or offered for inspection. sale(Sce.7044,Business&Professions Code) 2. I,as owner of the property,am exclusively contracting with licensed Signature of Applicant: contractors to construct the project(Sec.7044,Business&Professions Code). Date: /3$ /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. I will permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the 3. 1 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,Sections 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:8/3/2016 1 certify that I have read this application and state that the above information is CONSTRU��NDING 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 802016 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.orgCUPERTINOr 2 NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION/TI ❑ REVISION/DEFERRED ORIGINAL PERMIT# PROJECT ADDRESS f®q fl J�O� APN# ' 1 ®� OWNERNAME q PHONE T E-MAIL STREET ADDRESS ! 0 <-9 J "I-)a CITY, STATE,ZIP CONTACT NAME \®tt PHONE�t .7 � �� EMAIL STREET ADDRESS 3 i CITY,STATEJJZIP �,Bg_ �C �cqO C� FAX ❑OWNER ❑ OWNER-BUIIAER ❑`OWNERAGENT "91 CONTRACTOR El CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME �)- � LICENSE NUMBER q � LICENSE TYPE BUS.LIC# @ I o, COMPANY NAME i p E-MAIL l FAX °� STREET ADDRESS f LC. CITY,STATE,ZIP ellPHONE ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC# COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE r DESCRIPTION OF WORK pe G-A t .. vC422W J 1 ��r� f�lif`tL EXISTING USE PROPOSED USE - CONSTR.TYPE #STORIES USE TYPE OCC. SQ.FT. VALUATION($) EXISTG NEW FLOOR DEMO TOTAL - AREA AREA AREA NET AREA BATHROOM ��+ KITCHEN OTHER - REMODEL AREA 6.�S REMODEL.AREA REMODEL AREA PORCH AREA DECK AREA TOTAL DECK/PORCH AREA GARAGE AREA: EIDETACH ❑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 El YES IVED 13Y Q, - %Y1 TOT LVALUATION: PLANNING ADPL# ❑NO PLANNING APPROVAL LETTER EICHLER HOME? El ly d/e'� �{ By my signature below,I certify to each of the following: I am the property owner or authorized agent to Jet on the roperty 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/Agent: ' q ;tbhnDate: 9A 12-ID SUPPLEMENTAL INFORMATION REQUIRED Q Pr. cli�cz�:xP� ° xovT•u�resL>P.,>. New SFD or Multifamily dwellings: Apply for demolition permit for ovER T Cc�r1TR ❑ UIC DING riA>ti> v1Ew existing building(s). Demolition permit is required prior to issuance ofbuilding permit for new building. `.�xeREss ❑ TT ANIIINGPlAN REVIEW Commercial Bldgs: Provide a completed Hazardous Materials Disclosure ❑ STANDARD ""'" ❑ ruauci�aitxs " fo_rm if any Hazardous Materials are being used as part of this project. Copy of Planning Approval Letter or Meeting with Planning prior to .x; , ❑' �vrAaoiz ElsrrARysEwERDLSTRICT submittal of Building Permit application. z 1=. ., ❑;°ENVIRONMENTALHEALTH' B1dgApp_2011.doc revised 06121111