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B-2016-2073 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2016-2073 10080 N WOLFE RD CUPERTINO,CA 95014(316 20 086) T F MCGUCKIN INC MILPITAS,CA 95035 OWNER'S NAME: I&G DIRECT REAL ESTATE 27 LP DATE ISSUED:08/15/2016 OWNER'S PHONE:408-982-8433 PHONE NO:(408)263-5614 LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: License Class B Lic.#654239 Contractor T F MCGUCKIN INC Date 09/3012016 X BLDG _ELECT _PLUMB I hereby affirm that I am licensed under the provisions of Chapter 9(commencing MECH_RESIDENTIAL X COMMERCIAL with Section 7000)of Division 3 of the Business&Professions Cade and that my license is in full force and effect. JOB DESCRIPTION: I hereby affirm under penalty of perjury one of the following two declarations: SUITE SW3-250;T.I.-OFFICE AREA(16,714)-SUGARCRM 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 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 permit is issued. Sq.Ft Floor Area: Valuation:$460749.00 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 316 20 086 B(Tenant Improvements) 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 the Cupertino Municipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION, f Signature\ J Date 08/1.512016 Issued by Kim Dunbar Date:08/15/2016 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 i. 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(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:08/15/2016 i 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 California Health&Safe Code,Sections 25505,25533,and 25534. 1 will. Section 3700 of the Labor Code,for the performance of the work for which this. Safety 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 material.Additionally,should I use equipment or devices which emit hazardous shall not employ any person in any manner so as to become subject to the 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:0 8/1 51201 6 certify that Lhave read this application andstate 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 08/15/2016 Professional CONSTRUCTION PERMIT APPLICATION COWUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO,CA 95014-3255 C(,lf'EFtTINQ (408)777-3228• FAX(408)777-3333•buildina(ocupertino.o11(A( 2Q� ' ❑NEW CONSTRUCTION ❑ ADDITION ALTERATION/TI ❑ REVISION/DEFERRED ORIGINAL PERMIT# PROJECTADDRESS nn �( `i q� ( ,r� C IQ��� via 1'Y. Jllf�t/ W><'� -��} APN�I ���i(��` 4�� LJp'0 OIdtNERNAME PRONE ��. I��.��sl J E-MAIL STR>ET ADDRESS I g 05D .`(+ dtfp n!3' `� Or CITY,STATE,ZIP (� �t/ �, ,�/ FAX, CONTACT NAME PHONE £A4 I S# r 5TREETADPRFSS CITY,STATE,ZIP "M lnlf+ VOW CA-1 4� FAX 0 OWNER El OWNER-BUILDER 13 OWNER AGENT ❑ CONTRACTOR 0 CONTRACTOR AGENT ❑ AIZCIIITECT ❑ENawErR ❑ DEVELOPER ❑TENANT CONTRACTORNAME t r IENBS.!� t �7COMPANYNAME +� /1/�,j E-MAIL f} .f-pJRC LL h�C#& FAX 9TREETADDRCSS7�L' Ali I �"'II"1 CIiY,STATE,ZIP +Clptzq S v��3`� PHONE 3.oil ARCHITECTIENGINEER NAME MD`f I 'l0,1i LICENSENUMBER 6—+ t[j BUS.LIC# COMPANY NAME }N V , E-MAIL Q1 -- /�[{�(fr}'y�� J1 n• FAX STREETADDRESS CITY,STATE,.ZIP - � -ONE f - t1ftt ( Jtrltr ge3 CrS�,4o. .iia I� { 5 s M-lis PtI14 PWiK tA tom' 14D 5(41 W pWrk war_ iI;4 rtittW 3 IAVR h Ckf ur is -J d fl"p f'y"t- Talmo - ,!'"NPiW eqIAptA�rlt�+ EXIST'1NG USE PROPOSED USE �y, CONS'1'R.1YPE H STORIl'sS - - j� USE TYPE OCL'. SQ,F'f, VALUATION($) ";To NEW FLOOR^ DEMO TOTAL - - AREA , AREA rCAW AREA. NF.CAREA 'BATHROOM - KITCHEN - OTHER RE•MODELAREA REMODEL AREA REMODPLAREA PORCH AREA DECK AREA TOTAL DECKIPORCH AREA GARAGEAREA: DETACH -- - ATTACH #DWELLING UNITS: IS A SECOND UNDP []YFS SECOND STORY ❑YES BEING ADDED? [3ANO ADDITION? ANO PRE-APPLICATION ❑YES IF YES,PROVIDE COPY OF ISTIIEBLDGAN ❑YES - R EIVED13 OT LVALUA'1'10 PLANNING APPLA []NO PLANNING APPROVAL LETTER EICHLER HOME? ENO - ' By my Signature below,I certify to each of the following: I ani the property owner or authorized agen to act 613 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 enterthe above-identified property for inspection purposes. Signature of Applicant/Agent: Dater+ SIJPPLEMEN J 4 T[� A l ION REQUIRED T ! ..PLAACHECK T}'PE. .. . New SFA OY Multifamily dwellings:. Apply for deln011t1011 pet7lllt for ❑ Q!'ER THE-COUNTER _,, ❑ BUILDING PLAhREV1Z'.4!'. ((�{ . existing building(s). Demolition permit is required prior to issuance of building _ _.. permit for new building. ❑°Ea PRsss ❑ PLitNnlr.crl ar xEtiTeij _Commercial Bldgs: Provide a colnpletcd Hazardous Materials Disclosure L7 srs tnARD ❑ rUBLIC!loRKS form if any Hazardous Materials are being used as part of this project, - TCI LARGE ! ❑ ETRE DEPT_ _Copy of Planning Approval Letter or Meeting with Planning prior to ❑ ��>aoR ❑ sanrrAR�sI}l ERDISTIiICT subniittaI of Building Pennit application., ..:,. ..© ENS'IRONIiENTALHEALTH . B1dgApp_2011.doc revised 06121111