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B-2016-2562CITY OF CUPERTINO BUILDING PERMIT BUILDINGADDRESS: CONTRACTOR: PERMIT NO: B-2016-2562 21890 MEADOWVIEW IN CUPERTINO, CA 95014=1143 (326 45 025) NORTH VALLEY BUILDERS INC GILROY, CA 95020 OWNER'S NAME: AHMADI SASSAN AND AZIZI SHAHRNAZ TRUSTEE DATE ISSUED: 08/25/2016 OWNER'S PHONE: 408-439-0193 PHONE NO: (408) 687-0464 LICENSED CONTRACTOR'S AR TION BUILDING PERNHT INFO: License Class 11 Lie. #925966 Contractor NORTH VALLEY BUILDERS INC Date 92/31/2016 X BLDG —ELECT X PLUMB I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing X 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: KITCHEN REMODEL/RELOCATE (160 S.F.)REMODEL/RECONFIGURE I hereby affirm under penalty of perjury one of the following two declarations: DINING AREA (190 S.F.); REMOVE (E) 1. 1 have and will maintain a certificate of consent to self-insure for Worker's FP; RELOCATE FURNACE TO ATTIC; RELOCATE WATER HEATER Compensation, as provided for by Section 3700 of the Labor Code, for the TO GARAGE erformance of the work for which this permit is issued. have and will maintain Worker's Compensation Insurance, as provided for by fiction 3700 of the Labor Code, for the performance of the work for which this OP ermit is issued. Sq. Ft Floor Area: Valuation: $80000.00 APPLICANT CERTIFICATION certify that I have read this application and state that the above APN Number: - Occupancy Type: information is correct. I agree to comply with all city and county ordinances and state laws relating to building construction, and hereby authorize 326 45 025 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. Additionally, the applicant understands and will comply with all non-point WITHIN 180 DAYS OF PERMIT ISSUANCE OR source regulations per the Cupertino M ipal Code, Section 9.18. 1 Signature Date 08/25/2016 Issue y: M SSANAMES Date: 08/25/2016 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 (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: 08/25/2016 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. 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 Sections 25505, 2553 , and 25534. Labor Code, I must forthwith comply with such provisions or this permit shall i";` be deemed revoked. Owner or authorized agent APPLICANT CERTIFICATION Date: 08/25/2096 �,' I certify that I have read this application and state that the above information is CONSTRIIONLENDINGAGENCY correct. I agree to comply with all city and county ordinances and state laws I hereby affirm that there is a co struction 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 G.) 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 SiSignature Date 08/25/2016 9 Professional CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE CUPERTINO, CA 95014-3255 CCiPEEt'C►N (408) 777-3228 • FAX (408) 777-3333 buildlnq(O7cupertino.Orq 13 o 0 NEW CONSTRUCTION 0 ADDITION ❑ ALTERATION/ Ti ❑ REVISION / DEFERRED ORIGINAL PEPJ IIT # PROJECT ADDRESS 2_1 6APN R L�Vf e (Al 3 OWNERNAME T PHONE l 0 [A ! 1 q -57 �) FAIL STREET ADDRESS 2_19q0 M-fAdd CITY, STATE, ZIP . FAX CONTACT NAME 1_ClPHO E- AIL �% Ota a � % � S 1 fl e+a 11;7k"� STREET ADDRESS f CITY, STATE, ZIP V CIOFAXI mh El OWNER 11OA-NER-BUIIAER El OWNER AGENT 11 CONTRACTOR ElCONITRACTORAGENT M•a ❑ ARCHITECT ❑ ENGINEER El DEVELOPER ❑ TENANT CONTRACTOR -NAM J, 6 LICENSELICENTSE TYPE BUS. LIC` COMPANY N ' y� E-T\fAm 6 FAX j STREET ADDRESS CITY, STATE, ZIP PHONE BUS. LIC 13 LLRI 4£ t iJ ✓ �� S COMPANY NAME / E-MAIL FAX STREET ADDRESSA CITY, STATE, ZIP PHONE r DESCRIPTIONOFWORK__._ EXISTING USE PROPOSED USE CONSTR. TYPE a STORIES - USE TYPE OCC. SQ.FT. VALUATION (S) EXISTG�]p NEW FLOOR DEMO TOTkb ARIA. Gl g T AREA .511 ,f AREA 0 NET AREA BATHROOM KITCHEN OTHER- REMODELAREA. LfJ REMODEL AREA 1/O/ REMODEL AREA / 7 PORCH AREA D$CK AREA TOTAL DEC..L-r ,v H AKEA GARAGE AREA/ : ❑ DETACH [3ATTACH =' D WELLING UNITS: IS A SECOND UNIT E] YES SECOND STORY ❑ YES BEING ADDED? A NO ADDITION? ❑ NO PRE -APPLICATION ❑ YES IF YES, PROVIDE COPY OF IS THE BLDG AN ❑ YESRECENE , , L VALUATION: PLANNING APPL "r ❑ NO PLANNING APPROVAL LETTER EICHLER HOME? ; : �e U _ By my signature below, I certify to each of the following: I am the property owner or authorized agent to act erty owner's behalf. I have read this application and the information I have provided is correct. I have read the Description of )A7ork and verify ccurate. I agree to comply with all applicable local ' ordinances and state laws relating t buil g construct on. I authorize representatives of Cupertino to enter the above -identified property for inspection purposes. Signature of Applicant/Agent: Date: W � SUPPLEMENTAL INTFO ATION REQUIRED r : PLA�CHECKTYPE ` ROUTINGSLIP��, New SFD or Multifamily dwellings: Apply for demolition permit for 5 l p Ot ER THE COU ITER ❑BUIIab!N PLAiS RE�TES� existing building s). Demolition permit is required prior to issuance of building permit for new building. ❑ �aPREss ❑ PLAISRINGPLAN REQ IEV _ Commercial Bldgs: Provide a completed Hazardous Materials Disclosure ❑ sTANDRD ❑ rI sLlc 13oRLs To—nn if any Hazardous Materials are being used as part of this project. �` ` ❑ LARGE ❑ FIRE DEPT _ Copy of Planning Approval Letter or Meeting with Planning prior t0 JI44J0R ❑ SATSTTARYSEiiERDISTRICTt s subinittal of Building Permit application. r x \ B1dgf4pp_2011.doc revised 06121/11 NDN A - NV7d N0/1/70W: 70 - ffff _ 7 t- ,o __ _ ffff _ 7 t- ,o P/inz V A N V7alNOO 7---7/ Eil El El El El E"'I 1-1 E'l ["I E'l E'�] El �EK;l 'I, I 1�1'1 El 1-1