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B-2016-2132 I y CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: i CONTRACTOR: PERMIT NO:B-2016-2132' 19400 SORENSON AVE CUPERTINO,CA 95014-3446(375 03 005) LEON CONSTRUCTION CUPERTINO,CA 95014 OWNER'S NAME: FONTAINBLEU LLC DATE ISSUED:08/30/2016 OWNER'S PHONE:408-446-9898 PHONE NO:(408)209-1272 j LICENSED CONTRACTOR'S DECLARATION{ BUILDING PERMIT INFO: License Class B.C-10 Lic.#860272Contractor X BLDG _ELECT _PLUMB Y P X017 j I hereby affirm t II am licensed ed CONSTRUCTION deer thatee r/oviisions 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 herebyaffirm under penalty of perjury one of the BUILDING B-TEAR OFF;INSTALL OSB;INSTALL 60 MIL PVC p ty p ry I following two declarations: SINGLE PLY(893 SQ'S);INCREASE SLOPE;REPLACE(1)BEDROOM 1. 1 have and will maintain a certificate ofcousent to self-insure for Worker's EGRESS WINDOW 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:$50000.00 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: i and state laws relating to building construction,and hereby authorize 375 03 005 representatives of this city to enter upon the above mentioned property for inspection purposes. (We)agree to save indemnify and keep harmless the City f Cupertino accrue against said Cil ty inl os ns'eq encs of costs,and expenses which PERMIT EXPIRES IF WORK IS NOT STARTED ty against9 e granting of this permit. r WITHIN 180 DAYS OF PERMIT ISSUANCE OR Additionally,the apphcan n e tand and rill dimply with all non-point source regulations per e t ertin. Muni 'pal od ,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION. Signature Date 8/31/2016 Issued by:AbbyAyende Date:08/30/2016 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 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:8/31/2016 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. 1 have and will maintain Worker's Compensation Insurance,as provided for by I have read the hazardous materials requirements under Chapter 6.95of 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 a. I certify that in the performance of the work for which this permit is issued,I Health&Safety Code,Section 25532(a)shoo 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 equipme or devices which emit hazardous air contaminants as defined by the Bay Are Qu iy Man gem nt ,istrict I exemption,I become subjectst the Worker If,after making this certificate of will maintain compliance with the Cupe Muni pal Cod ,Chpt 9.12 and Compensation of California. s Compensation provisions of the ,, the Health&Safety Code e 4 s 255 ,25533, nd 5 4. i such provisions or this permit shall Labor Code,I must be deemed revoked.forthwith complywith Owner or authorized agent: y CATION Date:8/31/2016 APPLICANT CERTIFICATION CONSTRUCTION LENDING AGENCY I certify that I have read this application and state that the above information is correct./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 ARCHITECT'S DECLARATION and will comply with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. I understand my plans shall be used as public records. Licensed Signature Date 8/31/2016 Professional I 't i CONSTRUCTION (PERMIT APPLICATION COMMUNITI,DEVELOPMENT DEPARTMENT BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO,.CA 95014.325$ (408)777-3228 FAX(408)777-3333,building@cul)el,-tll-to.org CUPER .INO ilU to ❑NEW CONSTRUCTION ❑ ADDITI PROTECT ADDRESS � �ON : ALTERATION/TI ® REVISION/DEFERRED ORIGINAL PERMIT# fa !/1a1(r 11 APN i! � iJ OWNERNAM$ /�� i f'b ... PHON fp `!�/ :. E MAI t�6 L.h0Zr STREET ADDRESS rl CITY,STATR,ZJP n , l L 7 Y� e��c �-h'tq 6 F7JC2 L w6'- t?ft' CONTACT NAME j� �p ,., �[ /� �i. I✓yt Cj( �''� e PHOTS C4V Cj�";Ld fa�� E M U e 7` ociae STREETADDRVS I t�� CTT FcA E,ZIP Y d✓t) �� FAx��"�6"' C�t El oWNEP ® OWNER-BUILDER Cl OWNER AGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT 'D ARCHITECT D ENGINEER ❑ DEVELOPER n TENANT CONTRA OR ME LICBIt 1JivIB�R � LIC SEYPE BUS.LIC#} �j/(CJ MAILL I jFAX COMPANY O n ��n� � L I�, 1 l-e6 Y1�L�7 c /r(.t •I /jy! I(� l�4�i{Gk P A . STREET ADDRESS. r CITY STATE,Z[P PHONE ARCHITECT/ENGJNEERNAME LICFNSENUMBER / BUS.LIC# COMPANYN�MC E-MAIL F ' --:�l - tf STREET AD I S 1 CS1'ATE,%IP PH DBSCRIPTION OF W.QE C- _ _ EXISTING USE PROPOSED USE CONSTR.TYPE 11STORIES USE TYPE OCC, SQ.FT. VALUATION($) L•XISTO NEW FLOOR. DEMO TOTAL AREA AREA AREA NTT AREA - BATHROOM KITCHEN OT14ER REMODELAREA REMODELAREA REMODELAREA PORCHAREA DEC'KAREA TOTALDECKRORCIIAREA GARAGEAREA: DETACH [I AITACII " #DWELLINGUNITS: ISA.SECOND UNIT ❑YES SECONDSTORY ❑YES BEING ADDS)? I]NO ADDITION? D NO PRE-APPLICATION S IF,YES,PROVIE COPY___. I91111F R(A)G AN ❑YES RECEIV$D TOTAL VALUATION: PLANNING APPI,9 ❑OPLANNING APPROVAL LETTER EICHLERROME? LINO .: By my signature below,I certify to each of the following: I am the property owner or authorized agent to act rl the property owner's behalf. I have read this application and the information I have provided is correct, I have read the:Description of Mork and verify-it is accurate. I agree to comply with all applicable local Signature and state laws -_g g i •tion, o� �Iepresentatives of Cupertino to enter the above-identified property for inspection pu4loses. ordinances an state laws relating t tnldin const Date: SUPPLEMENTAL INFORMATION QUIRE - TLAN.�CHECK RO_UTlh G Sl:[P_; .. .. .:-..[ existingw SFD building(s).rMultDiat Demolition eelrnilt is for demolition perinit for y g p -`❑ 01 ER THE-COUNTERSUiLD1AGPLAN-Rk1Rk.11' required prior to Issuance of building omit for newbuilding. p p gp �PLANNI�GPLANREVIE}i.. ... .;._ _Commercial Bldgs: Provide a cornplatedjHazardous Materials Disclosure. :_0:ST;1N➢ARD = I] P1IBLIC�1'OI?KS form if any Hazardous Materials are being used as part of this project. ❑ LAxcI ❑ RiizEnr rr _Copy of Planning Approval Letter or Meeting with Planning prior to 0 a JDR_ ❑ SAN[TARI'sE\YER Dist Rlcr submittal of BuildingPen-nit application. _., -ENVIRO .° Ir:1SF,i1TAI.H1sAL1.H... BldgApp�_2011.doc7evised 06121111