B-2016-2910CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO: B-2016-2910
10494 MIRA VISTA AVE CUPERTINO, CA 95014-2706 (357 04 029) ROSS DAVID MC IVOR
SAN JOSE, CA 95125
OWNER'S NAME: BHAGWAT MAHENDRA J AND DEEPAVALI
OWNER'S PHONE:
LICENSED CONTRACTOR'S DECLARATION
License Class B Lie. #522948
Contractor ROSS DAVID MC IVOR Date 01/31/2018
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
IkSection 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. 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 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 licantht understands and will comply with all non -point
source regulat' per e Cupertino Municipal Code, Section 9.18.
Signature Date 6/13/2017
I hereby affirm that I am exempt from the Contractor's License Law for one of the
following two reasons:
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)
2. 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.
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.
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 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.
Signatu
DATE ISSUED: 01/04/2017
PHONE NO: (408) 286-5132
BUILDING PERMIT INFO:
X BLDG —ELECT —PLUMB
_ MECH X RESIDENTIAL _ COMMERCIAL
JOB DESCRIPTION:
1ST FLOOR BATHROOMS REMODEL (147 S.F.); CONVERT (E)
UNCONDITIONED PLAY ROOM TO FAMILY ROOM (155 SF);
MASTER BEDROOM/BEDROOM-3/NOOK (476 S.F.); RELOCATE
ENTRY DOOR AND CLOSED EXISTING DOOR OPENING; ADD (1)
SKYLIGHT
REV #1 - STRUCTURAL CHANGE - ISSUED 2/1/2017
REV #2 - KITCHEN REMODEL (378 S.F.); DINING ROOM, SITTING
ROOM, ENTRY REMODEL (653 S.F.); BATHROOM REMODEL (22.5
S.F.)- ISSUED 6/13/2017
Sq. Ft Floor Area: I Valuation: $73000.00
"N Number: Occupancy Type:
357 04 029 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: ABBY AYENDE
Date: 01/04/2017
RF ROOFS:
All roofs shall be inspected prior to any roofing material being installed. If a roof is
installed without fust obtaining an inspection, I agree to remove all new materials for
inspection.
Signature of Applicant:
Date: 6/13/2017
ALL ROOF
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 C e lino Municipal Code, Chapter 9.12 and
the Health & Safety Co , S ti ns 25505, 25533, and 25534.
Owner or authorized agent
Date: 6/13/2017
CONSTRUCTION LENDING AGENCY
I 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
ARCHITECT'S DECLARATION
Date 6/13/2017 1 understand my plans shall be used as public records.
Licensed
Professional
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR:PERMIT NO: B-2016-2910
10494 MIRA VISTAAVE CUPERTINO, CA 95014-2706 (357 04 029) ROSS DAVID MC IVOR
SAN JOSE, CA 95125
OWNER'S NAME: BHAGWAT MAHENDRA J AND DEEPAVALI
OWNER'S PHONE:
LICENSED CONTRACTOR'S RATION
License Class j3 Lic. #522948
Contractor ROSS DAVID MC IVOR Date 01131/2018
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
J
erformance 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. 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 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, th ap licant yhiderstands and will comply with all non -point
source regul io per the " upertino Municipal Code, Section 9.18.
Signatur Date 2/1/2017
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).
DATE ISSUED: 01/04/2017
PHONE NO: (408) 286-5132
BUILDING PERMIT INFO:
X BLDG —ELECT —PLUMB
_ MECH X RESIDENTIAL _ COMMERCIAL
JOB DESCRIPTION:
1 ST FLOOR BATHROOMS REMODEL (147 S.F.); CONVERT (E)
UNCONDITIONED PLAYROOM TO FAMILY ROOM (155 SF);
MASTER BEDROOM/BEDROOM-3/NOOK (476 S.F.); RELOCATE
ENTRY DOOR AND CLOSED EXISTING DOOR OPENING; ADD (1)
SKYLIGHT
REV #1 - STRUCTURAL CHANGE - ISSUED 2/1/2017
Sq. Ft Floor Area: Valuation: $73000.00
APN Number: Occupancy Type:
357 04 029 1 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: ABBY AYENDE
Date: 01/04/2017
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 of Applicant:
Date: 2/1/2017
I hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
t. 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.
APPLICANT CERTIFICATION
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 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.
Signature Date 2/1/2017
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 ea Air Quality Management District I
will maintain compliance with th u rtino Municipal Code, Chapter 9.12 and
the Health &Safety d ctions 25505, 25533, and 25534.
6wner or authorized age
Date: 2/112017
CONSTRUCTION LENDING AGENCY
I 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
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Licensed
Professional
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS:
CONTRACTOR:
PERMIT NO: B-2016-2910
10494 MIRA VISTAAVE CUPERTINO, CA 95014-2706 (357 04 029)
ROSS DAVID MC IVOR
SAN JOSE, CA 95125
OWNER'S NAME: BHAGWAT MAHENDRA JAND DEEPAVALI
DATE ISSUED: 01/04/2017
OWNER'S PHONE:
PHONE NO: (408) 286-5132
LICENSED CONT A TOR' -MCLARATION
BUILDING PERMIT INFO:
License Class GENERAL BUILDING CONTRACTOR Lic. #522948
Contractor ROSS DAVID MC IVOR Date 01/31/2018
X BLDG _ELECT _PLUMB
_
I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing
MECH X RESIDENTIAL COMMERCIAL
with Section 7000) of Division 3 of the Business & Professions Code and that my
license is in full force and effect.
JOB DESCRIPTION:
1ST FLOOR BATHROOMS REMODEL (147 S.F.); CONVERT (E)
I hereebb affirm under penalty of perjury one of the following two declarations:
UNCONDITIONED PLAY ROOM TO FAMILY ROOM (155 SF);
I have and will maintain a certificate of consent to self -insure for Worker's
MASTER BEDROOM/BEDROOM-3/NOOK (476 S.F.); RELOCATE
`C
Compensation, as provided for by Section 3700 of the Labor Code, for the
ENTRY DOOR AND CLOSED EXISTING DOOR OPENING; ADD (1)
performance of the work for which this permit is issued.
SKYLIGHT
,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.
Sq. Ft Floor Area:
Valuation: $73000.00
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
"N Number:
Occupancy Type:
and state laws relating to building construction, and hereby authorize
357 04 029
R-3 (Custom)
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 Cu rtino Municipal Code, Section 9.18.
180 DAYS FROM LAST CALLED INSPECTION.
` Date 01/04/2017
Issued by: Kim Dunbar
Date: 01/04/2017
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
m. 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.
sale (Sec.7044, Business & Professions Code)
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: 01/04/2017
I hereby affirm under penalty of perjury one of the following three declarations:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
-
t. 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
3. 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
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 Code, Chapter 9.12 and
exemption, I become subject to the Worker's Compensation provisions of the
the Health & Safety Code, Sections 2550, 5533, and 25534.
Labor Code, I must forthwith comply with such provisions or this permit shall
- (.
be deemed revoked.
Owner or authorized agent:. %
APPLICANT CERTIFICATION
Date: 01/04/2017
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 and state laws
CONSTRUCTION T. ND7N A1ENCY
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 inLender'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
1 understand my plans shall be used as public records.
Code, Section 9.18.
Licensed
Signature Date 01/04/2017
Professional