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15090031CITY OF CUPERTINO BUILDING PERMIT I;I BUILDING ADDRESS: 10200 N TANTAU AVE CONTRACTOR: DEVCON PERMIT NO: 15090031 I CONSTRUCTION INC OWNER'S NAME: ROCKTINO FEE LLC 690 GIBRALTAR DR DATE ISSUED: 09/21/2015 a OWNER'S PHONE: 4089961010 MILPITAS, CA 95035 PHONE NO: (408)942-8200 LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL ❑ COMMERCIAL ❑ 1 3 3 r RELOCATION OF A DOMESTIC BACKFLOW PREVENTER ON THE EAST SIDE OF TANTAU AVE IN CONFLICT WITH PROPOSED License Class_ Lic. # SIDEWALK ON APPLE MITIGATION INTERSECTION L-M Contractor fkvapor Const-• Date I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business & Professions i4 Code and that my license is in full force and effect. I hereby affirm under penalty of perjury one of the following two declarations: Sq. Ft Floor Area: Valuation: $17000 :. 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 7 performance of the work for which this permit is issued. APN Number: 31619061.10200 Occupancy Type: I have and will maintain Worker's Compensation Insurance, as provided for by I Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. PERMIT EXPIRES IF WORK IS NOT STARTED i APPLICANT CERTIFICATION WITHIN 180 DAYS OF PERMIT ISSUANCE OR I certify that 1 have read this application and state that the above information is correct. 1 agree to comply with all city and county ordinances and state laws relating 180 DAYS FROM LAST CALLED INSPECTION. to building construction, and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We) agree to save f L9J 1 indemnify and keep harmless the City of Cupertino against liabilities, judgments, Issued by:✓`-Ll�� Y V ll Date: 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 e Cupertino Municipal Code, Section 9.18. RE-ROOFS: "i Signature �"� Date —( 2 All roofs shall be inspected prior to any roofing material being installed. If a roof is installed without first obtaining an inspection, I agree to remove all new materials for inspection. ❑ OWNER-BUILDER DECLARATION Signature of Applicant: Date: I hereby affirm that 1 am exempt from the Contractor's License Law for one of 4 the following two reasons: ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER 1. 1, as owner of the property, or my employees with wages as their sole HAZARDOUS MATERIALS DISCLOSURE Y compensation, will do the work, and the structure is not intended or offered for j sale (Sec.7044, Business & Professions Code) 2. I, as owner of the property, am exclusively contracting with licensed contractors to I have read the hazardous materials requirements under Chapter 6.95 of the y construct the project (Sec.7044, Business &Professions Code). California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & I hereby affirm under penalty of perjury one of the following three declarations: Safety Code, Section 25532(x) should I store or handle hazardous material. t. I have and will maintain a Certificate of Consent to self-insure for Worker's Additionally, should I use equipment or devices which emit hazardous air Compensation, as provided for by Section 3700 of the Labor Code, for the contaminants as defined by the Bay Area Air Quality Management District I will h maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the performance of the work for which this permit is issued. Health & Safety Code, Sections 25505, 25533, and 25534. I{ 2. 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 Owner hpy* eda ng� t- r� i —Z S permit is issued. Date: 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 CONSTRUCTION LENDING AGENCY Compensation laws of California. If, after making this certificate of exemption, I I hereby affirm that there is a construction lending agency for the performance of work's become subject to the Worker's Compensation provisions of the Labor Code, I for which this permit is issued (Sec. 3097, Civ C.) must forthwith comply with such provisions or this permit shall be deemed Lender's Name revoked. Lender's Address APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is ARCHITECT'S DECLARATION correct. I agree to comply with all city and county ordinances and state laws relating I understand my plans shall be used as public records. 'i to building construction, and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We) agree to save Licensed Professional indemnify and keep harmless the City of Cupertino against liabilities, judgments, 9 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 II CUPERTINO CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 I (408) 777-3228 • FAX (408) 777-3333 • building(okupertino.ong /S aD3 ❑✓ NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION / TI ❑ REVISION / DEFERRED ORIGINAL PERMIT # PROJECT ADDRCoo NPN d / OWNER NAME. /JLLL PHONE 408-996-1010(Q E/ -MAIL K�attaneo@apple.com STREET ADORES 'y�� CITY, STATE, ZIP�y^ ^ nC�� FAX V/1 7JE-MAIL CONTACT NAME PHONE Sarah Nelson 323.919.4460 s.nelson@ccm.to STREET ADDRESS CITY, STATE, ZIP FAX 1 Infinite Loop MS -21-1 AC2 Cupertino, CA 95014 ❑ OWNER ❑ OWNER -BUILDER IZl OWNERAGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME LICENSE NUMBER LICENSE TYPE BUS LIC # Devcon Construction Incorporated CA Lic. 399163 COMPANY NAME E-MAIL FAX Devcon Construction Incorporated tcleveland@Devcon-const.com STREET ADDRESS CITY, STATE, ZIP PHONE 690 Gibraltar Drive Milpitas, CA 95035 408.964.5565 ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS. LIC # Stephen Yazalina SBE # 19730 COMPANY NAME E-MAIL FAX Sandis syaz@sandis.net STREET ADDRESS CITY, STATE, ZIP PHONE 1700 Winchester Blvd Suite 200 Campbell , am bell, Ca 95008 408.636.0900 DESCRIPTION OF WORK Relocation of a Domestic Backflow Preventer on the east side of Tantau Ave in conflict with proposed Sidewalk on Apple Mitigation Intersection L -M project plans EXISTING USE PROPOSED USE CONSTR TYPE # STORIES USE TYPE OCC. SQ.FT. VALUATION (S) EXISTG NEW FLOOR DEMO TOTAL AREA AREA AREA NET AREA $17,000.00 BATHROOM KITCHEN OTHER REMODEL AREA REMODELAREA REMODEL AREA PORCH AREA DECK AREA TOTAL DECKTORCH AREA GARAGEAREA: DETACH ❑ ATTACH #DWELLING UN ITS IS ASECOND UNIT []YES SECOND STORY []YES BEING ADDED? MNO ADDITION? ONO PRE -APPLICATION []YES IF YES, PROVIDE COPY OF IS THE BLDG AN ❑ YES RECEIVED B TOTAL VALUATION: PLANNING APPL # ❑ NO PLANNING APPROVAL LETTER EICHLER HOME? IZ NO�� [/ By my signature below, 1 certify to each of the following: I am the property owner or authorized agent to act on the property owner's behalf. 1 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. arize representatives of Cupertino to enter the above -i ntifie property for inspection purposes. Signature of Applicant/Agent: Date: 3 SUPPLEMENTAL INFORMATION REQUIRED PLAN CHECK TYPE ROUTING SLIP New SFD or Multifamily dwellings: Apply for demolition permit for ❑ OVER-THE-COUNTER BUILDING PLAN REVIEW existing building(s). Demolition permit is required prior to issuance of building permit for new building. ❑ EXPRESS PLANNING PLAN REVIEW Commercial Bldgs: Provide a completed Hazardous Materials Disclosure STANDARD PUBLIC WORKS form 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 to ❑ MAJOR ❑ SANITARY SEWER DISTRICT submittal of Building Permit application. ❑ ENVIRONMENTAL HEALTH B1dgApp_201 Ldoc revised 06/21/11