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B-2016-2428CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: CONTRACTOR: PERMIT NO: B-2016-2428 10504 DEMPSTERAVE CUPERTINO, CA 95014-1226 (326 48 030) ELEGANCE CONSTRUCTION SERVICES SAN JOSE, CA 95136 OWNER'S NAME: SINGH JIGNASA M AND MAIIESH OWNER'S PHONE: 408-761-2238 LICENSED CONTRACTOR'S D . RATION License Class GENERAL BUILDING CONTRACTOR Lic. #883037 Contractor ELEGANCE CONSTRUCTION SERVICES Date 08/31/2018 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. t 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. Date 10/4/2016 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: 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.. 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. L APPLICANT CERTIFICATION I certify that 1 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 indetnnify 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 10/4/2016 DATE ISSUED: 10/04/2016 PHONE NO: (408) 234-0604 PERMIT INFO: BLDG —ELECT —PLUME MECH X RESIDENTL&L _ COMMERCIAL JOB DESCRIPTION: ONE STORY LIVING ROOM ADDITION (192 S.F.); REMODEL (2) BATHROOMS TO CREATE (3.5) BATHROOMS (212 S.F.); REMODEL KITCHEN (200 S.F.); ADD BAY WINDOW TO LIVING RM. Ft Floor Area: 192 I Valuation: $120000.00 APN Number: Occupancy Type: 326 48 030 1 Deferred Submittal (R -3),R-3 (Custom) PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTION. Issued by: AbbyAyende Date: 10/04/2016 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 ofApplicant: Date: 10/4/2016 "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(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 Municipal Code, Chapter 9.12 and the Health & Safety Code, Sections 25505, 25533, and 25534. Owner or authorized agent: Date: 10/4/2016 CONSTRUCTION LENDING AGENCY 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 ARCffiTECT'S DECLARATION I understand my plans shall be used as public records. Licensed Professional �CUPERTINO I I 1 NAW (-()TJ1QTR7T1`-rTnN '(�.Zp1& _2qU CONSTRUCTION PERMIT APPLIC "TION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 . buildinp(ftupartino.org W:T1T)TTi(lTT rl ATTL-DATTIIT.T/TT 71 DL•NITTOTnTT!'n'0=Dnnn nn 7-T nnn111r QUIiAve 32& 46 WoPR4JEC!'ADDRESS APNYr OWNERNAME(n ,g � 1 t 1j �iJn\ (( PHO74t) �) . $ f V� EMAIL STREET ADDRESS � m J CITY, STATE, ZIP ,r % ,, (0_ Cs C •UL� PAX CONTACT NAME n' W ��' U �r{.r ft> PHONE PHONE 1R y `_. Ed19AIL 1'� . C� (LCT-T/+►�AftC 1b STREET' ADDRESS Cr 0. �lfl� *�/L. �1r1. CITY, STATS, ZIP e FAX ❑ OWNER ❑ OWNER -BOILER ❑ OWNERAUNT CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT 11 LNGAIP,L•R ❑ DEVELOPER ❑ TENANT CONTRACTORNAME (� a � / LICENSENUMBEli 5CS o3 L E PJt ( BUS. LIC ff 0 QA (� `"[+✓ \•�$�) COMPANY NAME f le �iY1+L e con,.T'��Vr,�" 1I04 jj/ EMA[LLj vkC- CG}YL✓tytAdrIr:Y/L4+ t o FAX STREET ADDRPSSjj ` - ,�. w _ CITY, STATE, ZIP 'get.,- V5 ry/j %515SPHONE o `''�"`BUS. 449g 1N _l ARCHITECTIENGINEE7RNAME LICENSENUMEER LIC COMPANY NAME B -MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE __.u_� _ - . _-_ _ - [ o AY'r- yo I c 0 V J' t V '�coi►�tef, EXISTING USE FROFOSED USE CONSTR. TYPE #STORIES USE TYPE OCC. SQ.FT. VALUATION ($} EXISTC. NEW FLOOR DEMO TOTAL AREA AREA AREA NETAREA BATHROOM KITCHEN - OTHER - - REMODELAREA' REMODELAREA REMODEL. AREA PORCH AREA DECICAREA TOT'ALDECK/PORCiIAREA GARAGEAR£A. ❑DETACH - 0 ATTACH f1DWELLINGUNITS: IS A SECOND UNIT ©YES SECONDSTORY ❑YES BEINGADDEb? ®NO ADDITION? ❑NO PRE-APPLICATTON ©YES IF YES, PROVIDE COPY Or - PLANNING APPL11 ONO PLANNING APPROVAL i FI 1'ER ISTHEBLDGAN 0YES EICHLER HOME? ❑ NO RE IV.E BYE ' TALVALUATION: S; VVproperty Y LV,VAI.(D 13y my signature below, l certify to each of the following: I air the property owner or authorized agent to act on t1 owner's behalf. I have read this application' and the inforination 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 build' coitstnnctio . authorize representatives of Cupertino to enter the above -identified property for inspection purposes. Signature of Applicant/Agent: � "-.�—� ^_` Date: SUPPLEMENTAL. INFORMATION REQUIRED Q PLAN CH.CCI{:TYPE. ❑.' OVER TH3<COUNTER ❑ BUIL'DIAG PL AA REl IE\! _ New SFr) or Multifamily dwellings: Apply for demolition permit for existing building(s). Demolition permit is required prior to issuance of building permit for new building. -I�,XPR> 3S _ :.:: U.PLNiRG YLAN ItEVIE� Commercial Bldgs: Provide a completed hazardous Materials Disclosure D: sTANDAIZD'>_;;.;-, - ❑ PUBLIC �i'ORiCS forn if any hazardous Materials are being used as part of this project. U�.LARGE,_.'... _ ::.:_::::.......: ❑ FIRE DEPT _ Copy of Planning Approval ,Letter or Meeting with Planning prior to _ ❑ n�naoR ❑ sAItiITATtY SE1iER D <STIUCT submittal of Building Permit application. - = - - BIdgApp 20ll.doc revised 06/211'11 ,?y4hk10