B-2016-3152 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2016-3152
10998 SYCAMORE DR CUPERTINO,CA 95014-6560(342 56 030) FURLANIC
CONSTRUCTION
REDWOOD CITY,CA
94061
OWNER'S NAME: GOTTLIEB ROBERT S AND MCDONOUGH JILL J TRUS DATE ISSUED:11/21/2016
OWNER'S PHONE:650-575-7339 PHONE NO:(650)888-0644
J.ICFNSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class U Lic.#675889
Contractor FURLANIC CONSTRUCTION Date 08/31/2017 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:
BATHROOM REMODEL-MASTER BEDROOM(125 S.F.);GUEST
I hereby affirm under penalty of perjury one of the following two declarations: BATHROOM#1(87 S.F.);GUEST BATHROOM#2(87 S.F.)
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.
/ 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:$74000.00
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 342 56 030
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 comply with all non-point
source regulations per the Cu.drti 6 Municipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
k Avasollw
Signature Date 11/21/2016 Issued by:AbbyAyende
�. Date: 11/21/2016
OWNER-BUILDER 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. N.
sale(Sec.7044,Business&Professions Code) `i
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:11/21/2016
I hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
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. 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
lJ\ 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
material.Additionally,should I use equipment or devices which emit hazardous
shall not employ any person in any manner so as to become subject to the
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 Municipal„ ,de,Chapter 9.12 and
exemption,I become subject to the Worker's Compensation provisions of the the Health&Safety Code,Sections 2550 and 25534.
Labor Code,I must forthwith comply with such provisions or this permit shall --
be deemed revoked. Owner or authorized agent: /1,6,” „-,-,---5: 7–
, .
APPLICANT CERTIFICATION j,-Date:11/21/2016
I certify that I have read this application and state that the above information is CONSTRUCTION LENDING AGENCY
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 ARCHITECT'S DECLARATION
Code,Section 9.18.- I understand my plans shall be used as public records.
Licensed
Signature Date 11/21/2016 Professional
b•-
?.�.Ot(Q- 2.,.
,/ CONSTRUCTION PERMIT APPLICATION
VCOMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
,i", , 10300 TORRE AVENUE•CUPERTINO,CA 95014-3255
-4,, (408)777-3228•FAX(408)777-3333•buildinq(a cupertino.orq
CUPINO
❑NEW CONSTRUCTION ❑ ADDITION ALTERATION/TI ❑ REVISION/DEFERRED ORIGINAL PERMIT#
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XOWNER ❑ OWNER-BUILDER 0 OWNER AGENT 0 CONTRACTOR 0 CONTRACTOR AGENT 0 ARCHITECT 0 ENGINEER 0 DEVELOPER. 0 TENAIL.T
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DESCRIPTION OF WORK
2� ( f 'i- S' s� 2� 1 l3 C7 J6./!✓% /1lCS `LC.�C ;
UP r R 4 p 6" l t' U3Bkl a‘ P u✓��.,s f4/6, /627—e.Cm,c . 17 7-1 L
EXISTING USE PROPOSED USE CONSTR.TYPE #STORIES
/ USE— TYPE OCC. SQ.FT. VALUATION($)
EXISTG NEW FLOOR DEMO TOTAL [ _ - I AREA AREA AREA. NET AREA
BATHROOM g p�y� KITCHEN OTHER -
REMODEL AREA ry/( I REMODEL AREA REMODEL AREA
PORCH AREA DECK AREA TOTAL DECKIPORCH AREA GARAGE AREA: ❑DETACH
0 ATTACH
#DWELLING UNITS: ISA SECOND UNIT El YES SECOND STORY ❑YES
BEING ADDED? 0 NO ADDITION? 0 NO
PRE-APPLICATION ❑YES IF YES,PROVIDE COPY OF IS THE BLDG AN ❑YES RE(~P ED$Yf , TOTAL VALUATION:
PLANNING APPL# ❑NO PLANNING APPROVAL LETTER EICHLER HOME? DO
NO -
By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on, e property owner's behalf. I have read this
' application and the information I have provided is correct. ..ave 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•g,co.structis+. uthorize representatives of Cupertino to enter the above-identified> property for inspection purposes.
Signature of Applicant/Agent: / Date: ( Z% 'C;
SUPPLEMENTAL INFORMA ON REQUIRED
,PLANCH>iCKTYPz /-? fir;, ;',ItOIITSNSLIE,,,, .,
New SFD or Multifamily dwellings: Apply for demolition permit for ❑.oyERTIE-COUNTER , - ❑,BIALDJNG FLAX VIEW✓,.,,.
existing building(s). Demolition permit is required prior to issuance of building
permit for new building. ❑ �xrxEss L� I ANNING P,L REVI W
Commercial Bldgs: Provide a completed Hazardous Materials Disclosure ❑ STANDARD ❑ 'PUBLIC IOR:FS
form if any Hazardous Materials are being used as part of this project. '
❑°LARGE ' ❑ FIRE DEPT.-
Copy of Planning Approval Letter or Meeting with Planning prior to
❑,.MAJOR ❑ SAhITARYSEw>RDISTRICT
submittal of Building Permit application. ';n
1,E iNVHLONMENTAL HEA'L'lTI
BldgApp_2011.doc revised 06/21/11