D-2016-0371 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:D-2016-0371
10308 N ST)LLING RD CUPERTINO,CA 95014-1644(326 30 088) RE ACQUISITIONS
GROUP INC
4335 CLAR1NBRIDGE
CIR DUBLIN,C 94568
OWNER'S NAME: RE ACQUISITIONS GROUP INC COW mitax
DATE ISSUED;03/29/2016
OWNER'S PHONE:925-998-0532 PHONE NO:OWNSk1BLDR
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO;
License Class Lie.#
At
Contractor RE A11S TJArot3-Kii-tOUP INC Date�
CQl _BLDG_ELECT _PLUMB
1 hereby affirm that I inn licensed under the provisions of Chapter 9(commencing —MECH RESIDENTIAL_COMMERCIAL
L
with Section 7000)of Division 3 of the Business&Professions Coda and that my
license is he full force and effect. JOB DESCRIPTION;
I hereby affirm under penalty of perjury one of the following two declarations: DEMO(E)1,346 S.F.SFD
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.
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.
Sq.Ft FIoor Arca: Valuation:$4000.00
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 326 30 088
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.
Additionally,the applicant understands and will comply with all non-point WITHIN 180 DAYS OF PERMIT ISSUANCE OR
source regulations per the Cupertino Municipal Code,Section 9.18. 180 DAYS FROM LAST . •••• •J_• ' ' i CTION,
Signature Date 03/29/2016 - —"�
Issued by: v � 1. Y ------- ��R
' Date:03/29/2016
OWNER-BUILDER DECLARATION
l 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 structure is not intended or offered for inspection.
Bye sale(Sec.7044,Business&Professions Code)
°'z, 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:03/29/201 6
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 - ALL ROOF COVERINGS BE CLASS"A"OR BETTER
Compensation,as provided for by Section 3700 of the Labor Code,for the �W
performance of the work for which this permit is issued. JIIAZARDOUS MATERIALS DISCLOSURE
z. 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 perforrnance 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
/s. I certify that in the performance of the work 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 manner so as to become subject to the material. Additionally,should I use equipment or devices which emit hazardous
Worker's Compensation laws of California, If,after making this certificate of oar contaminants as tlncen ew by tlta Bay Area Air Quality ode, a pre Dish and
will maintain compifanee with the Cupertino mi unicipal Code,Chapter 9,12 and
exemption,I become subject to the Worker's Compensation provisions of the the Heatth&Safety Code,Sections :5,25533,and 25534.
Labor Code,I must forthwith comply with such provisions or this permit shall
be deemed revoked,
Owner or authorized agent: ,Y
_
Date: ora/2016
APPLICANT CERTIFICATION1,21 ,
I certify that I have read this application and state that the above information is CONSTRUCTION LENDING GIINCV
correct.I agree to comply with all city and county ordinances and state laws I hereby affirm that there is a 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
and will comply with all non-point source regulations per the Cupertino Municipal ARCIIITECT'S DECI..AItATION
Code,Section 9.18. I understand my plans shall be used as public records.
Signature V . "'�' Date 03/29!2016 Licensed
Professional
N ` / DEMOLITION PERMIT APPLICATION
,.
' .•` ' COMMCINrn(DEVELOPMENT DEPARTMENT.BUILDING DIVISION -
"-tz�ss ° 10300 TORRE AVENUE.CUPERTINO,CA 95014-3255
J P ERTI ldC3 (408) 777-3228. FAX(408)777-3333.building af�cuper ino.orq
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..PROJECTADRESS e# u Ste/ / eCG ]ey � 4PN /j
_of •F2
OWNER NAME R /96,9441:6;711i91-7,s 97c, fi � ~ � _1
. lig)
IPHONE
(r,,2�S`9`%e—,s '3 z 1 E-MAIL meat/a;a m i.
STREET ADDRESS 36 cd oceI ae i7 ee;•-e./e, 1 CITY, STATE,ZIP .6Gcsg it ....... Rv.164t i //.S.4,4. FAX
CONTACT NAME A.74.d.,14,4: IvI6I�Ge441 PHONEEMAIL
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g �4.�� 3z i�al�tl�e 6 r fnr.fi 7L0..� �
STREETADDRESS 2 6, rn role!„, ce, CITY,STATE, Zip tvy,fl.Ssts3„con
!J FAX
E3 OWNER Ov PR-BUILDER 0 OWNER AGENT D CONTRACTOR 0 CONTRACTOR AGENT 0 AILCICTECTD ENGINEER. ❑ DEVELOPER• 0 TENANT
_
CONTRACTOR NAME LICENSENUMBERHUS.LIC
LICENSE TYPE
COMPANY NAME
1 E-MAIL FAX
.
STREET i CITY,STATE,ZIP PHONE
DESCRIPTION OF WORT{ �7!`l� Al," r' `' -r 9 T
RESIDENTIAL ` S� £ #f DWELLING :vim* `,�X VISAS .? u t: igt. t--o aSs- �" i
/ OFFICEUSE-{?NL:-Y..�` . „-a 5s .e ,,
FLOOR AREA UNITS �I '`'` ` :Ni yi s�,r'x- w1� g..- YY..f` '- r �r z-r
a : SE._--- t---OCC: 3,-• YPE.,ttAT--SO:FI4`.,,,, y-i VAI.ITA SON.,..-- s`
stCOMMERCIAL � ?'�:�'-"�:'-;:�`- +Y�-+c� '� tx= F"�. e -c xr
FLOOR AREA • a r V o+� x t,y . v ieiA K c
TYPE OF CONSTRUCTION{ t STGIUES sex - . i•i,-,,^'' f ' lig . 1_'F i . x-.S y xT a
ittae-
r
. VaI,AQIvID JOB NUMBER �laEtw +; s�1 �'• € TOTAL VALUATION
.4# 4 rsJ az T - i
d
By my signature below,I certify to each of the following: I am the property owner nthorized agent to act.,. . owner's•e r . ve read this
application and the information I have provided is correct. I have read the Description of Work and veil .t - into. I agree to comply with all app a local
ordinances and state laws relating to building construction. I.ukoiize representatives of Cupertino to enter the above-identified property for inspection purposes.
Signature of Applicant/Agent �� '_
8,21' 20
SUPPLEMENTAL INFORMATION REQUIRED P" OR TO ISSUANCE OF DEMOLITION PEWIT � ''k rEr °'�¢,
¢`s�� o�FrC.hlr"s�o��L�r
rA t .:
/Provide Job Number from Bay Area Air Quality Management District www.baaomd.org®415-749-4762. A...w_., L I,CIiECKTYPE .
Provide three copies(Residential)or six copies(Commerical)of a site plan showing protection for any trees 10" , xFss',
*
LDS av;`'`:
in diameter or more at 3'above grade. h glANII n
tf. Provide letter from POLE(40$-725-3325)stating all gas and electric has been disconnected. . L' tE h 1 `
xte tr t y.
I Provide a letter of inspection,tests,and abatement of any Hazardous Materials.Letter to be initiatedb3)person(s) zaaGR"r` ,' -,;r
Yp () :: Az- 3 A r�
cerci err in asbestos,mercury and/or hazardous material examination 3
11 nina Deet clearance to verify building is not considered an historical landmark.Allow 10 business days. °-� , '' r
Provide letter of clearance of all vermin from a licensed pest �.. .1 contractor. 4»` t , 0
if A. plicant shall call the Public Works Depat tnrent at R9...
}9777-3104 and schedule a"habitable dwelling'inspection. ` ,_a 1 *f" .f
Provide signed Debris Bin and Recyclable Materials form.
DenoApp_2013.doc revised 02/13/13
OWNER-BUILDER DISCLOSURE FORM
,.'
COMMUNITY DEVELOPMENT DEPARTMENT.BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO,CA 95014-3255 •
CUPERTINO (408)777-3228•FAX(408)777-3333•buildinoCn,cueertino.orq _..
•
Dear Property Owner(s):
An application for a building permit has been submitted in your name listing yourself as the builder of the property
improvements specified at: _.
SITE ADDRESS /0z24,2 s' e1��z :: . _ .:APfd.. r I Zai '
• OWNER NAME 3 7✓J OWNER ADDRESS;3,. /l L ceicko'7 C l c � . s'' I '4'S�!� • .
DESCRIPTION OF WQRKE t , . .. ,
S - 4
A.
We are providing you with an Owner-Builder Acknowledgment and Information Verification Form to make you aware of
your responsibilities and possible risk you may Incur by having this permit issued in your name as the Owner-Builder. We
will not issue a building permit until you have read,initialed your understanding of each provision,signed,and
returned this form to us at our official address indicated. An agent of the owner cannot execute this notice unless
you,the property owner, obtain the prior approval of the permitting authority,
OWNER'S ACKNOWLEDGMENT AND VERIFICATION OF INFORMATION
(DIRECTIONS:Please read and initial each statement below to signify you understand or verify this information.)
to w!'I. I understand a frequent practice of unlicensed persons is to have the property owner obtain an"Owner-
Builder"building permit that erroneously implies that the property owner is providing his or her own labor and material
personally.I, as an Owner-Builder,may be held liable and subject to serious financial risk for any injuries sustained by
an unlicensed person and his or her employees while working on my property. My homeowner's insurance may not
provide coverage for those injuries. I am willfully acting as art Owner-Builder and am aware of the limits of my
insurance coverage for injuries to workers on my property.
isss9s2. I understand building permits are not required to be signed by property owners unless they are responsible for
the construction and are not hiring a licensed Contractor to assume this responsibility.
raz3. I understand as an"Owner-Builder" I am the responsible party of record on the permit.I understand that I may
-protect myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her
name instead of my own.
04. I understand Contractors are required by law to be licensed and bonded in California and to list their license
numbers on permits and contracts.
fir, X2..5.I understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the
total value of my construction is at least five hundred dollars($500), including labor and materials, I may be
considered an"employer"under state and federal law,
m•m6. I understand if I am considered an"employer" under state and federal law,i must register with the state and
federal government, withhold payroll taxes, provide workers' compensation disability insurance, and contribute to
unemployment compensation for each "employee." I also understand my failure to abide by these laws may subject
me to serious financial risk.
I understand under California Contractors'State License Law, an Owner-Builder who builds single-family
residential structures cannot legally build them with the intent to offer them for sale, unless all work is performed by
licensed subcontractors and the number of structures does not exceed four within any calendar year,or all of the work
is performed under contract with a licensed general building Contractor.
j, .in 8, I understand as an Owner-Builder if I sell the property for which this permit is issued, I may be held liable for
any financial or personal injuries sustained by any subsequent owner(s)that result from any latent construction
defects in the workmanship or materials.
Oii'nerBuildertiiorrll 2010.doc revised 04/14/10
. I understand i may obtain more information regarding my obligations as an'employer'from the Internal
Revenue Service,the United States Small Business Administration, the California Department of Benefit Payments,•
and the California Division of Industrial Accidents. I also understand I may contact the California Contractors'State
License Board(CSLB) at 1-800-321-CSLB(2752) orwvrw,cslb.ca.gov for more information about licensed
contractors,
112-ri0. I am aware of and consent to an Owner-Builder building permit applied for in my name, and understand that i
am the party legally and financially responsible for proposed construction activity at the site address listed above,
14 44211, I agree that, as the party legally and financially responsible for this proposed construction activity, I will abide
by all applicable laws end requirements that govern Owner-Builders as well as employers.
•
'• A; -m12. I agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the
-
information I•have provided on this form. Licensed contractors are regulated by.,laws designed to protect the.public. If
you contract with someone who does not have a license,the Contractors'State License Board may be unable to
assist you with any financial loss you may sustain as a result of a complaint Your only remedy against unlicensed
•
• Contractors maybe in-civil court It is also important for you-to understand that if an unlicensed Contractor or
employee of that individual or firm is injured while working an your property,you may held liable for damages. If
you obtain a permit.as Owner-Builder and wish to hire Contractors, you will be responsible for verifying whether or not
those Contractors are properly licensed and the status of their workers' compensation insurance coverage,
CONSTRUCTION LENDING AGENCY
•
(DIRECTIONS:Please complete the following construction lending agency information.)
I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued
(Sec 3097 Civ.)
Lender Name: Lender Address:
Before a building permit can be issued,this form must be completed and signed by the property owner and
returned to the agency responsible for issuing the permit. Note:A copy of the property owner's driver's license,
form notarization, or other verification acceptable to t - c • may be required to be presented when the permit is Issued
to verify the property owner's signature.
Property Owner's Signature: -,ti,
Date: Z� b
(NOTE: The following Authorization Form is required to be co 'pleted by the properly owner only when designating an
agent of the property owner to apply for a construction permit for the Owner-Builder).
AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF
Excluding the Notice to Property Owner,the execution of which I understand is my personal responsibility, I hereby
authorize the following person(s)to act as my agent(s)to apply for, sign, and file the documents necessary to obtain an
Owner-Builder Permit for my project.
Scope of Construction Project(or Description of Work):
Project Location or Address:
Name of Authorized Agent: Tel No
Address of Authorized Agent:I .
declare under penalty of perjury that I am the property owner for the address listed above and I personally filled out the
above information and certify its accuracy.Note:A copy of the property owner's driver's license, form notarization, or other
verification acceptable to the city may be required to be presented when the permit is issued to verity the properly owner's
signature.
Property Owner's Signature: Date:
0)4merBujlderForni 2010 doc revised 04/14/10
Building Department
City Of Cupertino
10300 Torre Avenue
'ss Cupertino, CA 95014-3255
CUPERTINO Telephone: 408-777-3228
Fax: 408-777-3333
CONTRACTOR/SUBCONTRACTOR LIST'
JOB ADDRESS; ttiOt
5\d\A►it U PERMIT# - Zoi - 6 3 Fl
OWNER'S NAME: PHONE
GENERAL CONTRACTOR: C i kle,Jl (A\ BUSINESS LICENSE#
ADDRESS:
CITY/ZIPCODE:
*Our municipal code requires all businesses working in the city to have a City.of Cupertino business license.
NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTIONS) WILL BE SCHEDULED UNTIL THE
GENERAL CONTRACTOR AND ALL SUBCONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO
BUSINESS LICENSE.
I am not using any subcontractors: = f/(/ /2
Sign. ure Date
Please check applicable subcontractors and complete the following information: GL
SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE#
Cabinets &Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring/Carpeting
Linoleum/Wood
Glass/Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Painting/Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Date
Owner/Contractor.ignature