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B-2016-2711�ITY OF CUPERTINO BUILDING PERMIT BUILDINGADDRESS: CONTRACTOR: PERMIT NO: B-2016-2711 10001 N DE ANZA BLVD CUPERTINO, CA 95014-2263 (326 34 074) TCG BUILDERS INC MILPITAS, CA 95035 OWNER'S NAME: TAMBELLINI DEANZAPRO pERTIES LLC DATE ISSUED: 09/13/2016 OWNER'S PHONE: 415-310-5791 PHONE NO: (408) 321-6450 LICENSED CONTRACTOR'S DECLARATION,BUILDING PERMIT INFO; License Class B Lic. #835597 Contractor TCG BUILDERS INC Date D4L=20 X BLDG —ELECT —PLUMB I hereby affirm that I am licensed under the =ns of Chapter 9 (commencing. T MECH _ RESIDENTIAL X COMMERCIAL with Section 7000) of Division 3 of the Business & Professions Code and that my license is in full force and effect. JOB DESCRIPTION: T.I. PREP (22,108 S.F.) -APPLE I hereby affirm under penalty of perjury one of the following two declarations: t. I have and will maintain a certificate of codisent to self-insure for Worker's T.I. - B-2016-2710 Compensation, as provided for by Section 13700 of the Labor Code, for the performance of the work for which this permit is issued. ''2) I have and will maintain Worker's Compel sation Insurance, as provided for by L ,t,-Section 3700 of the Labor Code, for the performance of the work for which this Sq. Ft Floor Area: Valuation: $90000.00 ®® permit is issued. CATIONAPPLICANT CERTITI I certify that I have read this application and stat 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, aid hereby authorize 326 34 074 representatives of this city to enter upon the abo,fe mentioned property for inspection purposes. (We) agree to save indemgify 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 :he granting of this permit. Additionally, the applicant understands and will c mply with all non-point WITHIN 180 DAYS OF PERMIT ISSUANCE OR source regulations pert eC pe i o M .nicjarC de, section 9,18. 180 DAYS FROM LAST;CALLED INSPECTION. Signature Date 9/13/2016 Issued by: Abby e} ndg Date: 09713/2016 O R-B Tn 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 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 s cture is not intended or offered for inspection. sale (Sec.7044, Business & Professions C(de) z. I, as owner of the property, am exclusively contracting with licensed Signature of Applicant: contractors to construct the project (Sec.7C 44, Business & Professions Code)_ Date:/19 3/2016 I hereby affirm under penalty of perjury one of th following three declarations; ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER 1. I have and will maintain a Certificate of C resent to self-insure for Worker's Compensation, as provided for by Section 700 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 worC 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 manne 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 Mould al Code, Chapter 9.12 and exemption, I become subject to. the Worke 's Compensation provisions of the the Health & Safety Code, Section , 25533 an 4. Labor Code, I must forthwith comply with such provisions or this permit shall '} be deemed revoked. C ,Owner or authorized agent: APPLICANT CERTIFICATION Date: 9/13L2016 I certify that I have read this application and stat that the above information is correct. I agree to comply with all city and count ordinances and state laws I hereby affirm that there is a construction lending agency for the performance relating to building construction, and hereby aut orize representatives of this city of work's for which this permit is issued (Sec. 3097, Civ C.) to enter upon the above mentioned property for1ispection purposes. (We) agree Lender's Name to save indemnify and keep harmless the City of,Cupertino against liabilities, judgments, costs, and expenses which may accr a against said City in Lender's Address consequence of the granting of this permit. Addi�onally, the applicant understands and will comply with all npn-point source regulati ns per the Cupertino Municipal ARCHITECT'S DECLARATION 1 understand my plans shall be used as public records. Code, Section 9.18. Licensed Signature Date 9/1372016 Professional CONSTUCT'ION PERMIT APPLICATION j COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 Ci,IPER;TII� f](408) 777-32218 • FAX (408) 777-3333 • buildinq(c-cupertino.orq .', ; ❑ NEW CONSTRULTION ❑ ADDITI{DN ALTERATION / TI ❑ REVISION /DEFERRED ORIGINAL PERMIT # PROJECT ADDRESS R1VGZ APN n ONVINTER NAME .... PHONE E-MAILSPP , ,nc • d Md1lAy rlv,S�•�t t ex ilgj 5) c-wte STREET ADDRESS r CITY, STATE, ZI FAX CONTACT NAMEPHONE � � � J� � ". E-MAIL STREET ADDRESS $ PACcar4CITY, STATE, ZIP • FAX OWNER ❑ OWNER BUILDER ❑ OWNER A 'ENT 11 CONTRACTOR ❑ CONTTRACTORAGENT E ARCHITECT ❑ ENGINEER E DEVELOPER ❑ TENANT CONTRACTORNAME - � LICENSE NUMBER LICENSE TYPE i BUS. LIC 41 COMPANY NAME CU r e �� EMAIL r FAX 1. V r+�e,10 �3 V rldo✓sc • .321. G 45c STREET ADDRESS /ry_ , CITY, STATE, ZIP ,� ``+ j r j� r Cn_ �S PHONEB�• c ARCHITECT/ENGINEER NAA4EiA 0)1VV , v,� LICENSE NUMBER� BUS. LIC COMPANY NAME-MA1L FAX STREET ADDRESS ✓y C S"� CITY, STATE, J ZIP,�rJ PHONE � • / 6 �( DESCRIPTION OF N;ORC �_ ..to►t> �`"L1J�-t CU -fr 1�Lcry �"1 u N �✓... _... S 1 _ EXISTING USE J PROPOSED USE CONSTR. TYPE m STORIES " � r a V (? � USE TYPE OCC. � SQ.FT. I VALUATION {S} ED �-- � EXISTG /�2 J, W FLOOR DEMO TOTAL AREA -163 i A .EA AREA 2'�a1t NET cf BATHROOM V� dM KITCHEN J V OTHER REMODELAREMs REMODEL ARE REIII 0DEI,AR T� PORACH NCH A,�R�ET"A" DEAK®A#2EA TOTAL DE�CI1GPORCH AREA GARf)GE AREA; � ATTACH – — - DV,rEL A'G - 'ITS: , V/^��I[//TILS A SECOND UN, TIT' IQ YES SECOND DSSTORY E] YES - —� IV/A BELNGADDED? )KO ADDITION? rPi�O PRF-APPLICATION ❑ YES IF YES; PROVIDE COPY OF I IS THE BLDG AN �_L7 fYES CEIVED B ..� TOTAL VAL ATION:. PLANlIl G'APPL.r 0 PLANNING APPROVAL LETTER js EICHLERHODIE? INTO - )may le By my signature below, certify to each of the following: I am the property owner or authorized agen to act the property owner's behalf. I have read this application and the information I have provided is correct. I have read the Description Of AAlork and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating to bu� -i *�^ e representatives of Cupertino to enter.tbe above id tifi6fied property for inspection purposes. - 1 jj Signature ofApplicant/Agen Date: _ t� SUPP'!EiiIF-NTAL, INFORMS TION HECK TiPI IioKiTmG sr IP . ..; New SFD or Multifamily dwellings: Apply for demolition permit for o� ER TILE counTER BLILDInGPLAnRE\TEir W.Y existin; buildings). Demolition pen-nit is r quired prior to issuance of building 2 permit for new building. EXPRESS,�Pl S�IIvGPiAN 7u IE36 V 5 Commercial Bldss:. Provide,a complete Hazardous Materials Disclosure sTA.nARn ;PCBLIciFORis form if any Hazardou Materials ;are being u 3ed as part of this project./' LARGE FIRE DEPT _ Copy of Planning Approval Letter or Meeting with Planning prior to A1.AJOR ❑ SANITARi SESi'ERDISTRICT` submittal of Building,Pennit application. -. � ._ .,._ . ,. .. .. .. ❑.c ENVIRON!1iE?\TAL HEALTH'...' . . B1dg4pp._2017.doc revised 06/21111