B-2016-2769 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2016-2769
21522 REGNART RD CUPERTINO,CA 95014-4819(356 23 042) EAST/WEST
BUILDERS
SAN JOSE,CA 95117
OWNER'S NAME: MARTEN GARY L DATE ISSUED:09/21/2016
OWNER'S PHONE:408-868-8703 PHONE NO:(408)5612004
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class a Lic.#891264
Contractor EAST/WEST BUILDERS Date 08/31/2018 X BLDG _ELECT _PLUMB
MECH X RESIDENTIAL_COMMERCIAL
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. JOB DESCRIPTION;
(I)CONCRETE PORCH WITH STEP(60 SF)
I herd y affirm under penalty of perjury one of the following two declarations:
i. 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.
n 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:$1000.00
APPLICANT CERTIFICATION
1 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 56 Number: Occupancy Type:
3
and state laws relating to building construction,and hereby authorize 356 23 042
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. WITHIN 180 DAYS OF PERMIT ISSUANCE OR
Additionally,the applicant understands and will mply with all non-point
source regulations per the Cupe ina Municipal ode,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
Signature "� - ,. ate 09/21/2016 Issued by:Kim Dunbar
Date:09/21/2016
OWNER-BU11 DER 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
i. 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:09/21/2016
I hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
i. 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
maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
permit is issued.
Health&Safety Code,Section 25532(x)should I store or handle hazardous
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 material. Additionally,should I use equipment or devices which emit hazardous
air contaminants as defined by the Bay Area Air Quality Manag ent District I
Worker's Compensation laws of California. If,after making this certificate of will maintain compliance with the Cupertino Municip Code, er 9.12 and
exemption,I become subject to the Worker's Compensation provisions of the the Health&Safety Code,Sections 255058 2 33,and 4.
Labor Code,I must forthwith comply with such provisions or this permit shall (7 lv//
be deemed revoked. Owner or authorized agent: (�
APPLICANT CERTIFICATION Date:09/21/2016
I certify that I have read this application and state that the above information is CONSTRUCTION LENDING AGENCY
I hereby affirm that there is
correct.I agree to comply with all city and county ordinances and state laws 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 DECL Rr RAMM
and will comply with all non-point source regulations per the Cupertino Municipal I understand my plans shall be used as public records.
Code,Section 9.18.
Licensed
Signature Date 09/21/2016 Professional
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE• CUPERTINO,CA 95014-3255
(408)777-3228• FAX(408)777-3333•build ing(Qcupertino.org
CUPERTINO B-261&
�y
❑NEW CONSTRUCTION ❑ ADDITION ❑ AL ERAT ON/TI ❑ REVISION/DEFERRED ORIGINAL PERMIT 9
PROJECT ADDRESS nn ,_A J APN
OV,7NERNAME :. . V E-MAIL (�
STREET ADDRESS rr CITY, STATE,ZIP ( FAX
CONTACT NAMEPHON E Ati4IL
STREET ADDRESS CITY,STATE,ZIP
❑ oWNER ❑ owNTER-BuuDER ❑ o 'ER AGENT ❑ CONTRACTOR ❑CONTRACTORAGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPERS ❑ TENANT
CONTRACTOR NAME) p A _n LICEN t/R� d^h LICENSE TYPE /C BUS.LI
COMPANY NAME A E I`fAAIL % 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 �4 t VN
C CPI n
1-AX1STIU'G U PROPOSED USE CONSTR TYPE Y.STORIES
�' USE TYPE OCC. SQ.FT. VALUATION= -sA-/.�1 (S)
ISTG NEW FLOORt DEMO TOTAL
AREA AREA ' ® AREA NET AREA
BATHROOM KITCHEN' OTHER
REMODELAREA REMODEL AREA REMODEL AREA
PORCH AREADECK AREA TOTAL DECIGPORCH AREA IGARAGE.: DETACH
❑ATTACH
DAdELL\TG UNITS: Is A SECOND UNIT ❑YES SECOND STORY ❑YES
BEING ADDED? ENO ADDITION? []NO
Y
PRE-APPLICATION ❑YES IF Y'ES,PROVIDE COPY OF IS THE BLDG AN ❑YES1MUM
TA VAJjON:
PLANI�ZNG APPL []NO PLANNII.TG APPROVAL LETTER EICHLER HOME? ❑NO
By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on the property owner's behalf. I have read this
application and the information I have provided is correct. I have re the Descri ti of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating to bull g corlstraon. I autho ze represe es of Cupertino to enter the above- n ed prope o inspection purposes.
Signature of Applicant/A!ent: a (/ Date:
SUPPLEMENTAL INQ CHECK FORA4ATION REQUIRED TIPE
PLANr ,. zROUTINGSEIP_ F.N
New SFD or Multifamily dwellings: Apply for demolition permit forroan ;BUILDING PI a.REjTEM
existin�.building(s). Demolition permit is required prior to issuance of building
permit for new building4- RE\IEN
_Commercial Bldgs: Provide a completed Hazardous Materials DisclosureL7 sTA�DkR ❑ PLBiIC��oRxs r
form if any Hazardous Materials are being used as part of this project.
I] LARGE ❑ .FIRE DEPTx
_Copy of Planning Approval Letter or Meeting with Planning prior t0
submittalIFZAJOR ❑ S4YrTARY SER ERDISTRICT.
of Building Permit application.
❑ .ENVIROT��T�NTALFIEALTII'-- .c� -
B1dgApp_2011.doc revised 06121111