B-2016-2629CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO: B-2016-2629
19479 ROSEMARIE PL APT 3 CUPERTINO, CA 95014-3452 (375 01 007) HOMEOWNER
OWNER'S NAME: COHEN DAVID N ET AL
OWNER'S PHONE:
LICENSED CONTRACTOR'S DECLARATION
License Class Lic. #
Contractor HOMEOWNER BUILDER 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 Code and that my
license 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.
z. 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.
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 17
OWNER -BUILDER DECLARATION
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)
z. , I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec.7044, Business & Professions Code).
I hereby affirm under penalty of perjury one of the following three declarations.
t. 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.
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.
s. 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.
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 gr ing of this permit. Additionally, the applicant understands
and will comply wit I non -point source regulations per the Cupertino Municipal
Code, Section 9
Sigh ature Date/3/6 2017
ISSUED: 08/31/2016
NO:
BUILDING PERMIT INFO:
BLDG —ELECT —PLUMB
MECH X RESIDENTIAL _ COMMERCIAL
JOB DESCRIPTION:
KITCHEN REMODEL - M,E,P (82 S.F.)
REV #1 - BATHROOM REMODEL (100 S.F.)- ISSUED 3/6/2017
Sq. Ft Floor Area: I Valuation: $1050.00
APN Number: Occupancy Type:
375 01 007
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
Issued by: Abby A, ey nde
Date: 08/31/2016
RE -ROOFS:
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.
Signature of Al
Date: 3/6/2017
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
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(x) 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 theCuper ' o Municipal Code, Chapter 9.12 and
the Health & Safety Code, S ons 25505, 25533, and 25534.
Owner or authorized agent:
Date:/3 6/2017
CONSTRUCTION LENDING AGENCY
I 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
I understand my plans shall be used as public records.
Licensed
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
CUPERTINO (408) 777-3228 •FAX (408) 777-3333 • building@cupertinc.Org
[:]NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION/ TI ■ REVISION / EFERRED
ORIGINAL PERMIT # B-2016-2629
PROJECT ADDRESS 19479 Rosemarie PI, ## 3, Cupertino, CA
APN# 375-01-007
OWNERNAME Cohen David N et al
PHGNE650-766-9160
E-MAILdc94086@comcast.net
STREETADDRESS460 Fairfax Ave.
CITY, STATE, ZIP San Mateo, CA 9414.102
PAX
Moore CONTACT NAME Robert oor•e
PHONE408�7-824-1116
I E-MAIL robert@losnessgroup.com
STREETADDRESs33131 S Bascom Ave.,'#230
CITY, STATE, ZIP Campbell, CA 95008
FAX
❑ OWNER ❑ OWNER -BUILDER D OWNER AGENT ❑ ,CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME
LICENSE NUMBER
LICENSE TYPE
BUS. LIC #
COMPANY NAME
E-MAIL
FAX
STREET ADDRESS
CITY, STATE, ZIP
PHONE
ARCHITECT/ENGINEER NAME
LICENSE NUMBER
BUS. LIC #
COMPANY NAME
E-MAIL
FAX
STREET ADDRESS
CITY, STATE, ZIP
PHONE
DESCRIPTION OF WORK
Bathrooms: Remove and replace existing cabinets, plumbing and electrical fixtures, and tile, like -for -like.
T
EXISTING USE
PROPOSED USE CONSTR.
TYPE
#STORIES
USE
TYPE
OCC.
SQ.FT.
VALUATION ($)
EXISTG
NEW FLOOR
DEMO
TOTAL
AREA
AREA
AREA
NET AREA
BATHROOM
KTTCHEN
OTHER
REMODEL AREA
REMODEL AREA
REMODEL AREA
PORCH AREA
DECK AREA
TOTAL DECK/PORCH AREA
GARAGE AREA: DETACH
[:3 ATTACH
#DW -EL LING UNITS:
IS A SECOND UNIT ❑ YES
SECOND STORY ❑ YES
BEING ADDED? []NO
ADDITION? []NO
PRE -APPLICATION ❑YES IF YES, PROVIDE COPY OF
Is, THE BLDG AN ❑ YES
I�7,$j] fj
TOTAT. VALUATION:
PLANNING APPL # ❑ NO PLANNING APPROVAL LETTER
ETCHLER HOME? ❑ NO
By my signature below, I certify to each of the follo ing: I am the property owner or authorized agenho act on the property owner's behalf. I have read this
application and the information I have provide ' 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 builddiin onstruction. I authorize representatives of Cupertino to enter the above-identi 'ed p operty for inspection purposes.
Z+� f
Signature of Applicant/Agent: Date:
SUPPLEMENT C TION REQUIRED
PLAN SCK TYPE
ROUTING SLIP
❑ OVFWTr _C0Vr4`` ER
❑ BWWWG PLAN nvxw
_ New SFD or Multifamily dwellings: Apply for demolition permit for
existing building(s). Demolition permit is required prior to issuance of building
permit for new building.
171 ''EXPRESS
❑ PLANNING PLAN REVIEW
Commercial Bldgs: Provide a completed Hazardous Materials Disclosure
❑ STANDARD
❑ PUBLIcWORKS
form if any Hazardous Materials are being used as part of this project.
❑ LARGE
❑ F7RE'DEI"i`
_ Copy of Planning Approval Letter or Meeting with Planning prior to
MAJOR
( SAAi TARY SEWER, DISTRICT
submittal of Building Permit application.
❑ ENVIRONMENTAL UEALTII
BldgApp_201 Ldoe revised 06/21/11
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO: B-2016-2629
19479 ROSEMARIE PLAPT 3 CUPERTINO, CA 95014-3452 (375 01 007) HOMEOWNER
BUILDER
I OWNER'S NAME: COHEN DAVID N ET AL I DATE ISSUED: 08/31/2016
OWNER'S PHONE: 650-766-9160
License Class Lic. #
Contractor HOMEOWNER BUILDER 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 Code and that my
license is in full force and effect.
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. Sq. Ft Floor Area: Valuation: $1050.00
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 APN Number: Occupancy Type:
and state laws relating to building construction, and hereby authorize 375 01 007
representatives of this city to enter upon the above mentioned property for
inspection purposes. (We) agree to save indemnify and an 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.
PHONE NO:
BUILDING PERMIT INFO:
BLDG —ELECT _ PLUMB
MECH X RESIDENTIAL _ COMMERCIAL
JOB DESCRIPTION:
KITCHEN REMODEL- Il (82 S.F.)
M, F—;
Signature Date 8/31/2016
[ hereby affirm that I am exempt from the Contractor's License Law for one of the
rollowing 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)
7 2. I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec.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.
I have and will maintain Worker's Compensation Insurance, as provided for by
f 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.
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 gra 'ng of this permit. Additionally, the applicant understands
and will comply with I on -point source regulations per the Cupertino Municipal
Code, Section 9.1 .
,Signature Date 8/31/2016
Issued by: AbbyAyendg
Date: 08/31/2016
RE -ROOFS:
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.
Signature of Applicant:
Date:7 18 3 /2016
ALL ROOF COVERINGS TO BE CLASS "A" OR
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 cipal Code, Chapter 9.12 and
the Health & Safety C;Z7
5505, 25533, and 25534.
Owner or authorized agent:
Date: 8/3112016 CONSJJJ!!�UON LENDING AGENCY
I 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
I understand my plans shall be used as public records.
Licensed
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • C'UPERTINO, CA 95014-3255
(408) 777-3228 FAX (408) 777-3333 • buildingp_cupertina.oLg
LJ NEW CONSTRUCTION ❑ ADDITION N ALTERATION / TI ❑ REVISION / DEFERRED ORIGINAL PERMIT #
PROJECT ADDRESS 19479 Rosemarie PI, # 3, Cupertino, CAIAPN# 375-01-007
OWNER NAME
Cohen David N et al PHONE 650-766-9160 E-MAIL dc940869comcast.net
STREETADDRESS460 Fairfax Ave.. CITY, STATE, ZIP San Mateo, CA 94402..IT 7X
CONTACT NAME Robert Moore PHONE t08-82/0-1 1.16 E-MAILrobert@)IOsrlessgroup.com
STREET ADDRESs3 131 S Bascom Ave., 7Y230 CITY, STATE, ZIP Camtpbell,CA 95008_F
0 OWNER ❑ OWNER -BUILDER X OWNER AGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAMELICENSE NUMBER LICENSE TYPE
Tim Heath 863821 Elect BUS. LIC #
L
COMPANYNAME Star
1 (X Lighting q Electric E-MAIL heath833Pgmail.com FAX
RE
STREET A1111'
all l CITY, STATE, ZIP PHONE
3860 Oakes Dr. Hayward, CA 94542 (650) 787-7250
ARCHITECT/ENGINEERNRME LICENSE NUMBER BUS. LIC #
I COMPANY NAME I E-MAIL I FAX
I STREET ADDRESS I CITY, STATE, ZIP I PHONE
DESCRIPTION OF WORK
Upgrade kitchen electrical systems to current code.
PROPOSED
I EXIST TTAL
NEWI AREAFLOOR I D� I NETAREA
USE I TYPE I OCC. I SQ.FT.
BAIHROOM KITCHEN OTHER - I
REMODEL AREA REMODEL AREA REMODEL AREA
PORCH AREA I DECK AREA I TOTAL DECK/PORCH AREA I GARAGE AREA: FIDETACH
ATTACH
VALUATION ($)
#DWELLfNGUNITS:IS A SECOND UNIT YES SECOND STORY ❑YES
BEING ADDED? []NO ADDITION? [-]NO
PRE -APPLICATION ❑ YES IF YES, PROVIDE COPY OF IS THE BLDG AN ❑, YES EjVAR11 ; , . ' TOTAL VALUATION:
PLANNING APPL# NO PLANNING APPROVAL LETTER EICHLER HOME?❑NO .^ $1,050
By my signature below, I certify to each of th ollowing: I am the property owner or authorized agent o act do the property owner's behalf. I have read this
application and the information I have pro ed correct, I have read the Description of Work and verity it is accurate. I agree to comply with all applicable local
ordinances and state laws relating to bu m ons ction. I authorize representatives of Cupertino to enter the above-identi -ied pr perry for inspection purposes.
Signature of Applicant/Agent: Date: �i �� b _
SUPPLEMENTAL INFORMATION REQUIRED
New SFD or Multifamily dwellings: Apply for demolition permit for
existing building(s). Demolition permit is required prior to issuance of building
permit for new building..
Commercial Bldgs: Provide a completed Hazardous Materials Disclosure
form if any Hazardous Materials are being used as part of this project.
Copy of Planning Approval Letter or Meeting with Planning prior to
submittal of Building Permit application.
BldgApp_2011.doc revised 06/21/11
. 1 ulid r tand l'
lever! Service, the
and the CbWornia .1v
Licehsa Board(CSLE
am the paw leq lly,and fi
TT- l agree that, as tf
fl', applicable, laws and
rawer tttlderfb 2t l U,t �c a� vas tl l I a i;