B-2016-2449 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2016-2449
20324 GILLICK WAY CUPERTINO,CA 95014-4413(369 36 038) LEGEND
CONSTRUCTION INC
SAN MATEO,CA 94402
OWNER'S NAME: HIRAI FRED M AND DONNA R TRUSTEE i DATE ISSUED:08/03/2016
OWNER'S PHONE:408-489-0947 PHONE NO:(650)799-4979
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO-
License Class B Lic.#805708
Contractor LEGEND CONSTRUCTION INC Date 06/30/2018 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:
I hereby affirmunder penalty of perjury one of the following two declarations: MASTER BEDROOM BATHROOM REMODEL(36 S.F.)
i. 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..
z. "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:$15000.00
APPLICANT CERTIFICATION
certify that I have read this application and state that the above
information is correct.I agree to comply with all city and county ordinances APN Number: Occupancy Type;
and state laws relating to building construction,and hereby authorize 369 36 038
representatives of this city to enter upon the above mentioned property for
inspection purposes. (We)agree to save indemnify and keep harmless the
City of Cupertino against liabilities,judgments,costs,and expenses which PERMIT EXPIRES IF WORK IS NOT STARTED
may accrue against said City in consequence of the granting of this permit. WITHIN 180 DAYS OF PERMIT ISSUANCE OR
Additionally,the applicant understands and will comply with all non-point
source re tie r the Cupertino unicipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
C_
Signature Date.. /$�1Q�C Issued by:Abby A ey nde
Date:08/03/2016
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 is
t. 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 of Applicant:
contractors to construct the project(Sec.7044,Business&Professions Code). Date:8/3/2016'
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
a 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
s. 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 , e ' s 25 05,25533,and 25534.
Labor Code,I must forthwith comply with such provisions or this permit shall
be deemed revoked. Owner or authorized agent:
APPLICANT CERTIFICATION 7 Date: //8 3 2016
1 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 8/3/2016 Professional
.........__._...................__.......
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255
CUPERTIN (408)777-3228 FAX(408)777-3333•buildingC�cupertino.org � ��-&-
❑NEW CONSTRUCTION El ADDITION �TERATION/TI ElREVISION/DEFERRED ORIGINAL PERMIT# `(
PROJECT ADDRESS q
2-03-LL/ 1 �Ir /c `CPN A 7� % 031
OWNERNAME
/ E-MAIL
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J /l y tl f PHONE 7—W1, P f i
STREET ADDRESS�7 1f / /�� y
G-I-¢�� •r r �I CITY,STATE,ZIP r G� l✓� FAX
CONTACT NAME
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ST-3-1. D ll�F Pw CITY,STATE Je,§ T FAX
❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT �'CONTRACTOR ❑CONTRACTOR AGENT ❑. ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME LICENS NUMBER LICENSE TYPE BUS.LIC#
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COMPANY NA7 p �) 1
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ST. ET ADD SS CITY,STATE,ZIP PHONE
407
ARCHITECTBNGINEER NAME Ave-
LICENSE NUMBER BUS.LIC#
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
DESCRIPTION 01111
34
EXISTING USE PROPOSED USE -CONSTR-TYPE. #STORIES - _ _.
USE TYPE OCC. SQ.FT. VALUATION($)
EXISTG NEW FLOOR DEMO TOTAL
AREA AREA AREA NET AREA p��i 6
BATHROOM KITCHEN OTHER _ 11 Cs�
REMODEL AREA REMODEL AREA REMODEL AREA `
PORCH AREA DECK AREA TOTAL DECKIPORCH AREA I GARAGE AREA: EIDETACH -
❑ATTACH
#DWELLING UNITS: IS A SECOND UNIT ❑YES SECONDSTORY ❑YES
BEINGADDED? ONO ADDITION? E]NO
PRE-APPLICATION ❑YES IF YES,PROVIDE COPY OF IS THE BLDG AN ❑YES RECEIVED BTr: 'rVTAL VALUATION:
PLANNING APPL# ❑NO PLANNING APPROVAL LETTER EICHLERHOME? ❑NO6 C6
s
By my signature below,I certify to each of the following: I am the property owner or authorized agent to&I on thd property owner's behalf. I have read this
application and the information I have provided is correct. I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws rel tin fUd' o tion. I a e representatives of Cupertino to enter the above deentified property for inspection purposes.
Signature of Applicant/Agent: / Date: J tip
SUPPLEMENTAL INFORMATION REQUIRED "
PLAN CHECK TYPI IJT
IN
yG SLIP
New SFD or Multifamily dwellings: Apply for demolition permit for �] OVER-TICo[JIYTE ® Buy bH*IE PIANutEvs f .
existing building(s). Demolition permit is required prior to issuance ofbuilding -
permit for new building. " XP5
❑ PIANNING PLAN RE1 IEtiV
Commercial Bldgs: Provide a completed Hazardous Materials Disclosure STANDAIID ❑ Pl BLiGw0ltxs
form if any Hazardous Materials are being used as part of this project.
'.LARGE ,, `� ❑°�IREDEPT:"i ,
_Copy of Planning Approval Letter or Meeting with Planning prior to JQR - x', ] +r�A$xsswE$nxszcT
submittal of Building Permit application.
❑'ENiTIRONIVIENTAL'HEALTHI.
BldgApp_2011.doc revised 06121111