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B-2016-1846CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: CONTRACTOR: PERMIT NO: B-2016-1846 21599 EDWARD WAY CUPERTINO, CA 95014-4764 (356 19 008) ELITE HOME DEVELOPMENT SAN JOSE, CA 95128 OWNER'S NAME: CHIU KAREN KO-YUEN OWNER'S PHONE: 501-332-2652, LICENSED CONTRACYOR'S DECLARATION License Class.B Lie. #925917 Contractor ELITE HOME DEVELOPMENT Date 12/31/2016 hereby affirm that I am licensed under the provisions of Chapter 9 (commencing dth Section 7000) of Division 3 of the Business & Professions Code and that my cense is in full force and effect. I hereby affirm under penalty of perjury one of the following two declarations: 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. 2. 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. I certify that 1 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 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 with all non -point source regulations per the Cupertino Municipal Code, Section 9.18.. Date 08/26/2016 I hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: 1. I, 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) 2. I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Scc.7044, Business & Professions Code). I hereby affirm under penalty of perjury one of the following three declarations: 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. 2. 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. 3. 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 become subject to the Worker's; Compensation provisions of the Labor Code, I must forthwith comply with such provisions or this permit shall be deemed revoked. j APPLICANT CERTIFICATION 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 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 with all non -point source regulations per the Cupertino Municipal Code, Section 9.18. Signature Date 08/26/2016 DATE ISSUED: 08/26/2016 PHONE NO: (408) 838-8400 PERMIT INFO: BLDG —ELECT —PLUMB MECH X RESIDENTIAL _ COMMERCIAL JOB DESCRIPTION: ADDITION (360 S.F.) TO EXTEND MSTER BEDBATHAND FAMILY ROOM; RECONFIGURE/REMODEL (E) KITCHEN (190 S.R); REMODEL (E) HALL BATH (63 S.F.); RECONFIGURE AREA TO CREATE (N) LAUNDRY AND HALF BATH (60 S.F.) Sq. Ft Floor Area: 360 1 Valuation: $100000.00 APN Number: Occupancy Type: 35619 008 R-3 (Custom) PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTION. Issued by: Kim Dunbar RF, -ROOF: All roofs shall be inspected prior to any roofing material being installed. If a roof is installed without fust obtaining an inspection, I agree to remove all new materials for inspection. ture of Applicant: 08/26/2016 ALL HAZARDOUS MATERIALS DISCLOSURE I have read the hazardous materials requirements under Chapter 6.95 of the California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Section 25532(a) should I store or handle hazardous material. Additionally, should I use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management District I will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Sections 25505, 25533, and 25534. Owner or authorized agent: 1\,, –, t' I/ I % ✓� Date: 08/26/2016 CONSTRUCTION LENDING AGENCY hereby affirm that there is a construction lending agency for the performance of work's for which this permit is issued (Sec. 3097, Civ C.) Lender's Name Lender's Address ARCHITECT'S DECLARATION understand my plans shall be used as public records. CUPERT11NO T.--F'(IV CDTSTTti it'TTt�N %C CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT - BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255' (408) 777-3228 - FAX (406) 777-3333 a buildinoa-cupertina,ora V'\t. AT]T]TTT01J F AT TF'R 4•I'ti rnt I IT T7 DrViCIn7 /Tl".T7LDDCTI l'LL1 TP_T1.F A T' h'�n t e•r+n PRt0IECTADDRESS APT O\�ERT53 PHOTS r ��-"-• G t4 r STkF-B'I ADDRESS 2 l t9 -C Vj CITY, sTATE, ZIP„+++ :. F X -- `Lt CONTACT K'AME.�� // // tla1 L �^"���4� �14-o`- PHOT£ �� � r56t� t7 (1g � � F �C.Zi/l.�,V !7f 9 6MAd. STREETDbRE$S ` �' a /�1e CI TY, STATE, ZIP -30se c�zF,2X 80sz- 01AMER Cl OWIER-B1iA-DER ❑ 0NrhER.',WNT COMULkCTOR 1:1 CO TR4CTOP AGENT ❑ ARCHITECT ENGN-EER ❑ AEt?LOPER ❑ TENANT CO:RTRACTORNAME ` -� L]CH]vSETt]My LIC£>:SETTPE3US.LIC - E-h4AiLZ�t FAX COAiPATYNA?,5F 41 f_ e- jCir STREFT.4DDRFSS l CITY, STATE, ZIP // G.�” 6 Cit � (/�' ' .J� ✓`:'S'E� Vy`�� PHO]E G �OeS�® ���rf ItRC.I3ITECTrEt�GI] IF.R?iih�iE �10ENSEhL1h5BER — C0I:iP.z]��YNkhSE -� E-h�.SIL �r �. r !'f[ � � �i 4 :�t � (( jf�/ tt(. C flnj 1 FA -'K 4 b? (J STREET ADDRESS CITY, STATE, ZIP FP 44 SO 070'x' -'.1E5 _ T10T ,: - , s EY,]STTt4O USE TITZ € R STORIES-� LISE - VZTF I`I OCC. }I�SQr-. VL-UAmiON"(S") -- MSTG TWFLOOF DEmo TOTAL -- — EArttES ARE TT4PEi T C///r���r-•?. V1=" l00 BATHP100h{ KITCHEN OTI tR RU.iODELAREA f REMODEI_AREA y 6r REMODEL AREA PORCN ARF.9 nTzC} IKEA TOTAL DIEChlPORC.y ARIA I GkP AGE AREA: Z� t1ETACH I _ gATTACIi --- ` -" ----� r DWF-LLIt,�G UK -ITS: T]5 A SECQ:+D Lt\IT - ❑ )'ES SEC0'�D STORY ©1'ES - - - - —t Ij B=NG"DFD' FgNO PF.F A-PPLICATI0M ©Y --S W YES.PROYIDECOPY 0E— PLA 'TIIGAPPI! [:),-0 PLA1, N-0 APPROVAL LETT ER ISTAF.BLDGA.\Y ❑`ESctZ�C�I�Ej3$Y ncitLERRol,rE? �NO TOTALVAWATIOV' coo By nay sigrature belov.,, I certify to each of the folloveiug: I ant the property owner or authorized agent to act on the property owners behalf. I have read this appl [cation and the information 1 have provided is correct. I have read the Description of ttrorl, and verify it is zccurate. I agree to con?ply With all applicable local ordinances and state laths relating to building r.. s6vction. I autbo ize. representaTives of Ct~perthl-lo to enter the above -[dent[ edfpp/ property -for inspection purposes. Si��natareafApplicarL/Agent _ Date: +_' CS/{"j41 -- SLIPPLE',IF IN OnCC ,TIO'N RdQ UIR.F17 New SPIE or lvlultifaill]ly dwellings: Apply forderno)itlon pern-lit fOr pxt "`' -u � ❑ O ERT k C{}L\TER ��� �` �- �'�� �� "-'� ... � . x SLSLTII�G PI RFl I£Zi existing building s). Derlolition pe] alit is required prior to issz -nce of b]lilding p� � �t ; 4 . pen -nit for new building. m - , .i s ❑jPrii� _ Camrle-tial BI.dbs Provide a coniple ed Hazard0us Mater; Is Discl0sureST iai_ 7 if any I azardous tv a ials are b.;rtg used as Da) t o tt„s T roject. 55 LAIRD h � �� PLBLICS 4]�I�J s -e] ❑ Z nGEP4 L� FIPEDEPT �� _ C'opy of Plzilnintr'Approval Letter or Mectiwt tsith Plannirg prior to - - ❑ Stibrnittal of Building Permit application._ t- ArOR xz' �` �-' S�y7T�.R1=Ett'£RbIcTR1C?_(:>_ ;'�'°......, ._._.,_� ,.�':cr�� �:❑fE\\-tRO.�\aE'�TAI:l3EQLT'H =: Z;IT 3r tkk .qo B1dd pp_20J1.doc remised 06121111 9