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NOT CUPERTINO B-2016-2795 F CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2016-2795 13995 MONTEBELLO RD CUPERTINO,CA 95014-5456(351 17 030) FUTURE VISION REMODELING INC VAN NUYS,CA 91406 i OWNER'S NAME: TERRY IONS DATE ISSUED:09/26/2016 OWNER'S PHONE:774-423-6674 PHONE NO:(800)485-4919 LICENSED CONTRACTOR'S DRCLARATIML BUILDING PERMIT INFO: License Class 5 Lia#991840 X BLD _ LECT _ LUIVIB Contractor FUTURE VISION REMODELING INC Date 04130/2018 RESEDEN 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 SCRIPTION: IST FI OR MASTER BA OOM(150 S.F.) 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 a Labor Code,for the /performance of the work for which this permit is iss d. a: I have and will maintain Worker's Compensation ance,as provided for by / Section 3700 of the Labor Code,for the performanc f the work ich this C\ - � permit is issued. Sq. Are aluatton:$3000.00 APPLICANT CERTIFICATION IL certify that I have read this application and state that the ove information is correct.I agree to comply with all city and co my or nances APN,Nu er: Occu ancy and state laws relating to building construction,and hereby uthor a 351 1'7 030 representatives of this city to enter upon a above mention d pro rty for inspection purposes. (We)agree to save 1 emnity and kei ha ss the City of Cupertino against liabilities,judgmen costs,and a enses hich PERMIT E S IF RK IS NOT S TED may accrue against said City in consequence f the grantin f this it. WITHIN 180 YS O PERMIT I SUAN E OR Additionally,the applicant understands and wil mply with I non-poi source regulations per the Cupertino Municipal e,Sectio 9.18. 1$0 DAYS FRO T CALLED SPE TION. i Signature to Issue by. bby�yende Datq: 016 .,,,._ 1AI \>A OWNER-BUILDER DECLARATION % - V-A I hereby affirm that I am exempt from the Contractor's License L or one of the following two reasons: /fled\w:ith be insrior tF'Jeon.material being installed.If a roof is �. I,as owner of the property,or my employees with wages as their sole t firskkp g aniee to remove all new materials for compensation,will do the work,and the structure is not intended or offer for 1sale(Sec.7044,Business&Professions Code) a. I,as owner of the property,am exclusively contracting with licensed Si 'tore of A t: contractors to construct the project(Sec.7044,Bus' as&Professions ode D I hereby affirm under penalty of perjury one of the followin declaration pOF COVE S TO BE CLASS"A"OR BETTER 1. I have and will maintain a Certificateof Consent to a for Work s Compensation,as provided for by Section 3700 of the r or th performance of the work for which this permit is issued. RIALS DISCLOSURE 2. I have and will maintain Worker's Compensation hisuran s provided for by Lh, a th zardo materials requirements under Chapter 6.95 of the Section 3700 of the Labor Code,for the performance of the rk for which this ea ety Code,Sections 25505,25533,and 25534. I will ermit is issued. mpliance with the Cupertino Municipal Code,Chapter 9.12 and the p Safety Code,Section 25532(a)should I store or handle hazardous 3. I certify that in the performance of the work for which this peImlt is issued,Iditionally,should I use equipment or devices which emit hazardous shall not employ any person in any manner so as to become subject to the ants s defined by the Bay Area Air Quality Management District I Worker's Compensation laws of California. If,after making this certificate of n pliance with the Cupertino Municipal Code,Chapter9.12 and exemption,I become subject to the Worker's Compensation provisions of theealth&Safety Code,Sections 25505,25533,and 25534. Labor Code,I must forthwith comply with such provisions or this permit shall be deemed revoked. Ovuni r or authorized agent:T APPLICANT CERTIFICATION Date:9/26/2016CONSTRUC3ION LENDIN A FNCw I certify that I have read this application and state that the above information is I hergby a correct.I agree to comply with all city and county ordinances and state lawsaffirm that there is a construction lending agency for the performance relating to building construction,and hereby authorize representatives of this city of w Wa for which this permit is issued(Sec.3097,Civ C.) to enter upon the above mentioned property for inspection purposes. (We)agree Len;er's Name to save indemnify and keep harmless the City of Cupertino against liabilities, Lender's Address judgments,costs,and expenses which may accrue against said City in 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 I understand my plans shall be used as public records. Code,Section 9.18. Lice sed Signature Date 9/26/2016 Prof ssional `t_),Ia�- LT�I� �"J CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT�BUILDING DIVISION , 10300 TORRE AVENUE•CUPERTINO, CA 95:cupertino.ong 4-3255 1` LAildin CUPERTINO (408)777-3228• FAX(408)777-3333• bu ❑NEW CONSTRUCTION El ADDITION 2p ALTERATION )/TSI ❑ VISION/DEFERRED ORRIQII AL PERMIT# PROJECT ADDRESS 11 T p �C� )�O �e� 1 G tAf" }�`��/ N Ji5 l^ l�Jell OWNER NAME—, �Glls PHONE ^I 7t2��/b _hLA.IL STREET ADDRESS CITY, STATt,ZIP I FAX CONTACT NAME ©y OT NE k5g) STREET ADDR2 JqJ Jqs�� av(? El CIAWER ❑1 OWNER-BUILDER /L/Y✓t�l�i(I�C/o G,(1CS17q AIL ❑ OWNER AGENT RCO RCONTT O AGENT ❑''PARC( IHITECT ❑ DEVELOPER ❑ TENANT CONTRACTOR NAMFn_ n v��O 9 e��4�� EN UMBE i LICENSE TYPE BUS.LIC R COMPANY NAME �F©l�`I ` i E i �©eAl FAX STREET ADDRESS /T Y,STATE,ZIP ,, J�p�1 PHON p 'N ARCHITECT/ENGINTEER NAME I/NSE NUMBER BUS.LIC 4 COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE . �SJ DESCRIPTION OF WORK _ ,kje A� to EXISTING USE PROPOSED US CONSTR.TYPE O S USE E CC. SQ.FT. VALUATION(S) EXISTG NEW FLOOR DEMO AL AREA AREA AREA • BATHROOE4 KIT EN OTHER REMODELAREA P7 ODEL AREA REN40DEL A PORCH AREA DECK AREA TOTAL DECI PORCHAREA GARAGE AREA: DETACH ❑ATTACH DWELLING UNITS: ISA SECOND UNIT ❑YES SECOND STORY []YES BEINGADDED? ❑NO ADDITION? ❑NO PRE-APPLICATION Z 1'FS IF YES,PROVIDE COPY OF IS THE BLDG AN ❑YESCEIVI:D BY , TAL VALUATION: PLANN'NG APPL#Jn NO PLAT.'NN'G APPROVALLETTER EICHLER HOME? ❑NO s I ,F,a;: ' ¢ z` .: By my sign e below,I certify to each of the following: I am the property owner or autho zed agent o act o the property owner's behalf, I have read this applicati and the information I have provided is correct. I have read the Description of Wok and verify it is accurate. I agree to comply with all applicable local ordinan s and state laws relating to building consv gLigu— I authorize representatives Of Cu ertino to enter the above-identified property for inspection purposes. SigzlatureofApplicanUAgent: Date: Z? ? yIPE ` fSUPPLEMENTAL INFORMATION REQUIRED CCT `, .:ROUTINGSLIP z, New SFD or Multifamilydwellings: Apply for demolition ennit for PP y P aOVER THE-COUNTER � BUiLDII�G PLAN R3ti1�IE1'1 existing building s). Demolition pen-nit is required prior to issuance of building D EaPRESS fl'.PLAIITING PLAN RE1IE10 permit for new building. t,� � �K�s ��4 _ Commercial Bldgs: Provide a completed Hazardous Materials Disclosure STAn1)ARn` , r ❑ PtrBLlci`oRxs form if any Hazardous Materials are being used asart of this project. ; ❑ ]IRE AEPT P P ❑ LARBE ` _Copy of Planning Approval Letter or Meeting with Planningprior to r 0 r � s iiAliY sE1�ERDISTRICT ` s 1,I3JOR r t s submittal of Building Permit application. ,p ENVIRONI�IEi\TAli HEALTH:;. BIdgAPP_2011.doc rerised 06121111 il�