B-2017-0053 CITY OF CUPERTINO BUILDING PERM T
BUILDING ADDRESS: CONTRACTOR: P:RMIT NO:B-2017-0053
20654 MAPLETREE PL CUPERTINO,CA 95014-0449(323 45 042) L U CONSTRUCTION
INC
NEWARK,CA 94560
OWNER'S NAME: MOE KEITH E D.TE ISSUED:01/10/2017
OWNER'S PHONE:408-480-2067 P.ONE NO:(866)735-5558
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT I 0:
License Class¢ Lic.#1013006
Contractor 1,U CONSTRUCTION INC Date 04/30/2018 X BLDG —ELECT ' UMB
I hereby affirm that I am licensed under the provisions of Chapter 9(commencing —MECH X RESIDEN AL—COMMERCIAL
RCIAL
with Section 7000)of Division 3 of the Business&Professions Code and that my
license is in full force and effect. JOB DESCRIPTION:
2ND FLOOR BATHROO REMODEL(52 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 the Labor Code,for the
'1 ',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. A Sq.Ft Floor Area: V• uation:$10000.00
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: 0.cupancy Type:
and state laws relating to building construction,and hereby authorize 323 45 042
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 EXPI' S IF WORK IS NOT STARTED
may accrue against said City in consequence of the granting of this permit. WITHIN 180 D• S OF PERMIT ISSUANCE OR
Additionally,the applicant understands and will comply with all non-point
source regulatio er the Cupertino Municipal Code,Section 9.18. 180 DAYS FRO LAST CALLED INSPECTION.
Signature Date 1/10/2017 Issued by:AbbyAyende
Date:01/10/2017
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.rior 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 obta' 'i g 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:1/10/2017
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. HAZARD US 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&Saf ty Code,Sections 25505,25533,and 25534. I will
permit is issued. maintain compliance with t e Cupertino Municipal Code,Chapter 9.12 and the
3. I certifypermit in the performance of the work for which this is issued,I Health&Safety Code,S ction 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,sho d I use equipment or devices which emit hazardous
air contaminants as define 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,Sectio 25505,25533,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:1/10/2017
I certify that I have read this application and state that the above information is CONSTRUCTION LENDING AGENCY
I hereby affirm that there
correct.I agree to comply with all city and county ordinances and state laws 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 per it 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
1
and will comply with all non-point source regulations per the Cupertino Municipal ' SHIT ' E L;�.=_
Code,Section 9.18. I understand my plans shal be used as public records.
Signature Date 1/10/2017 Licensed
Si
9 Professional
?),2D- 1:1,- Off
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CONSTRUCTION PERMIT APPLICATION
,:...... COMMUNITY DEVELOPMENT DEPARTMENT•BUILDINGUNITY DEB
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41.04.4,, 10300 TORRE AVENUE•CUPERTINO,CA 95014-3255
CUPERTINO (408)777-3228•FAX(408)777-3333•buildinq(a,cupertino.orq
❑NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION/TI ❑ REVISION/DEFERRED ORIGINAL PERMIT#
PROJECT ADDRESS
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ar reesz pi APN# `}� _0/12_
OWNER NAME 14 VI/ ( t,�� PHONE Lo g..4 o _2®v E-MAIL
STREET ADDRESS �,. Ley` CITY,STATE,ZIP FAX
Id,.r� ! e T�eEL f li ccipertthA i (A,' RI
CONTACT NAME )1ukf., ' PHONE/S Sq 42. E-MAIL
STREET ADDRESS CITY,STATE,ZIP FAX
ElOWNER El OWNER-BUILDER 0 OWNER AGENT 0 CONTRACTOR !CONTRACTOR AGENT 0 ARCHITECT 0 ENGINEER ❑ DEVELOPER 0 TENANT
CONTRACTOR NAME L(J /O _ ` v 9 N LICENSE NUMBER 10 12 j�h 6, LICENSE TYPE BUS.LIC#
COMPANY NAME L ` v E-MAIL Jllu FAX
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STREET ADDRESS PHONE
S otl 1 g S al e�b; Le_14' „• CITYr. ,STATE,ZIP�e �Y1 f e A 1 ,4 J1,C Rik- 4-3.r- S cb
ARCHITECT/ENGINEER NAME 11 is If✓\LICENSE NUMBER BUS.LIC#
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
DESCRIPTION OF WORK
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EXISTING USE PROPOSED USE CONSTR.TYPE #STORIES
USE TYPE OCC. SQ.FT. VALUATION($)
EXISTG NEW FLOOR DEMO TOTAL
AREA AREA AREA NET AREA
BATHROOM !� KITCHEN OTHER
REMODEL AREA J REMODEL AREA REMODEL AREA
PORCH AREA DECK AREA TOTAL DECK/PORCH AREA GARAGE AREA: 0 DETACH
0 ATTACH
#DWELLING UNITS: ISA SECOND UNIT DYES SECOND STORY ❑YES
BEING ADDED? ❑NO ADDITION? ❑NO
PRE-APPLICATION ❑YES IF YES,PROVIDE COPY OF IS THE BLDG AN 0 YES RECEIVED B TOTAL VALUATION:
PLANNING APPL# 0 NO PLANNING APPROVAL LETTER EICHLER HOME? 0 NO
By my signature below,I certify to each of the following: I am the property owner or authorized agen to act an the property owner's behalf. I have read this
application and the information 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 building construe i i authorize representatives of Cupertino to enter the above-identified��a, property for inspection purposes.
Signature of Applicant/Agent: -+u+ Date: I fib/i
SUPPLEMENTAL INFORMATION REQUIRED PLAN CHECK TYPE ROUTING SLIP
New SFD or Multifamily dwellings: Apply for demolition permit for ❑ OVER-THE-COUNTER ❑ BUILDING PLAN REVIEW
existing building(s). Demolition permit is required prior to issuance of building
permit for new building. ❑ EXPRESS - ❑ PLANNING PLAN REVIEW
Commercial Bldgs: Provide a completed Hazardous Materials Disclosure ❑ STANDARD ❑ PUBLIC WORKS
form if any Hazardous Materials are being used as part of this project.
CI LARGE ❑ FIRE DEPT
_Copy of Planning Approval Letter or Meeting with Planning prior to ❑ MAJOR ❑ SANITARY SEWER DISTRICT
submittal of Building Permit application.
0 ENVIRONMENTAL HEALTH
BldgApp_2011.doc revised 06/21/11