B-2017-0059 CITY OF CUPERTINO BUILDING PERM T
BUILDING ADDRESS: CONTRACTOR: P:RMITNO:B-2017-0059
10631 S S FOOTHILL BLVD CUPERTINO,CA 95014-3963(342 16 087) PRESTIGE PLUMBING
MENLO PARK,CA
94026
OWNER'S NAME: SCR ENTERPRISES LLC D TE ISSUED:01/11/2017
OWNER'S PHONE:408-674-5961 P.ONE NO:(650)754-3151
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT I 0:
License Class C-36 Lic.#904747
Contractor PRESTIGE PLUMBING Date 10/31/2017 XBLDG ELECT X 'I UMB
MECH RESIDENT • X 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:
HELLO WORLD CAFE-EXTEND(2)PLUMBING LINES(40'&10')
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.
`� <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: V.luation:$1900.00
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: O cupancy Type:
and state laws relating to building construction,and hereby authorize 342 16 087
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'I S IF WORK IS NOT STARTED
may accrue against said City in consequence of the granting of this permit. WITHIN 180 D YS OF PERMIT ISSUANCE OR
Additionally,the applicant understands and will'comply with all non-point
source regulations per the upeNino Municipal Code,Section 9.18. 180 DAYS FRO I LAST CALLED INSPECTION.
Signatur
Date 01/11/2017 Issued by:ME '` `►�� : i
Date:01/11/2017
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 roofmg 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 ob .• • 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:01/11/2017
I hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF CO RINGS TO BE CLASS"A"OR BETTER
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. . _-- S .T - • D • R
2. I have and will maintain Worker's Compensation Insurance,as provided for by I have read the hazardou 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 he 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,S coon 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 • 'th the Cupertino Municipal Co ,Chapter 9.12 and
exemption,I become subject to the Worker's Compensation provisions of the the Health&Saf:ty Code ions 5505,25 Tan ,534.
Labor Code,I must forthwith comply with such provisions or this permit shall
be deemed revoked. Owner or authorized age t'
APPLICANT CERTIFICATION Date:01/11/2017 '
I certify that I have read this application and state that the above information is N. IR LE !� A
correct.I agree to comply with all city and county ordinances and state laws I hereby affirm that there i-a construction lending agency for the performance
relating to building construction,and hereby authorize representatives of this city of work's for which this pe 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
and will comply with all non-point source regulations per the Cupertino Municipal =. �i T' D._ .__; a.II
Code,Section 9.18. I understand my plans sha I be used as public records.
Licensed
Signature Date 01/11/2017 Professional
4 CONSTRUCTION PERMIT APPLICATION
vCOMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
1.4,s 10300 TORRE AVENUE•CUPERTINO,CA 95014-3255
CUPERTINO (408)777-3228•FAX(408)777-3333•buildinci cupertino.orq / Oa
'
El NEW CONSTRUCTION El ADDITION ❑ ALTERATION/TI 11 REVISION/DEFERRED ORIGINAL PERMIT#
PROJECT ADDRESS I ° a i S 6 116 % 6 APN# 3 ci 2 // , 0 Q
OWNER NAME 5�I Cik' _ Lr15,.e. tial
alPHONEjos�'Y 7 y''' E-MAIL
STREET ADDRESS 0p , ci DI vex,SAT,ZIP Ge....45 15.07 V
FAX
ES
CONTACT NAME U�- om.IA PH01 660.)®L 1, -MAIL
STREET ADDRESS
`d3,2_ (�` _y s laxi, CE P eelo C,.LAy 303 FAX
❑OWNER 0 OWNER-BUILDER 'D OWNER AGENT 0 CONTRACTOR 0 CONTRACTOR AGENT D ARCHITECT 0 ENGINEER 0 DEVELOPER ❑TENANT
CONTRACTOR NAME pao 0,4 ce d LICENSE NUMBER�� y,?,9 LICENSE TYPE ` BUS.LIC# q a ?5.8.,
COMPANY NAME y J Q4 c Q t 101441 1 SC/ 60rE-MAIL �e-511-4&Oak FAX
STREET ADDRESS "25 CPO i S. A-I `Q l.� 0.44rCITY,STATE,ZIP LCL `j q S^b3 PHONE
ARCHITECT/ENGINEERNAME 4s' LICENSE NUMBER [ Cali cJ' BUS.LIC# ,,.°,
COMPANY NAME E-MAIL '�„r+'�'_ FAX !' orf”
STREET Al c°A SS CITY,S ,ZIP ` 9,- P ONE
DESCRIPTION OF WORK / 01 / ,�1,, / J r_./ /fitte 7eX'Z' \' ®:F4 iJ
/nS141 (11 , 0 c))— Drei t/0 2 fO ° /—,rFVC cIfec -LP 3/
EXISTING USE PROPOSED USE I CONSTR.TYPE 1 #STORIES USE TYPE OCC. SQ.FT. VALUATION($)
EXISTG I NEW FLOOR DEMO I TOTAL
AREA AREA AREA NET AREA
BATHROOM KITCHENI OTHER
REMODEL AREA REMODEL AREA REMODEL AREA
PORCH AREA DECK AREA TOTAL DECK/PORCH AREA GARAGE AREA: ❑DETACH
0 ATTACH
#DWELLING UNITS: ISA SECOND UNIT DYES SECOND STORY DYES
401110
BEING ADDED? 0N ADDITION? ONO rii-
PRE-APPLICATION ❑YES IF YES,PROVIDE COPY OF IS TIlE BLDG AN .iil7 _ �!TAL VALU'> !N:
PLANNING APPL# ❑NO PLANNING APPROVAL LETTER EICHLER HOME? ❑NO - �%"--R
I�
400
By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on the property owner's be,alf.4 have read this
application and the information I have provided is correct. -have read the Description of Work and verify it is accurate. I agree to comply with all appli able local
ordinances and state laws relating to s 'lei'g e 1 stru.(I authorize representatives of Cupertino to enter the above-identii♦e s :I o s'*for
ms ectio purposes.
ill.
Signature of Applicant/Agent: e� /` ��� ( ��
Date:
i
SUPPLEMLNTAL 1, 0 Ft ION 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. 0 EXPRESS 0 PLANNING PLAN REVIEW
Commercial Bldgs: Provide a completed Hazardous Materials Disclosure 0 STANDARD 0 PUBLIC WORKS ,
form if any Hazardous Materials are being used as part of this project. ❑ LARGE 0 FIRE DEPT
_Copy of Planning Approval Letter or Meeting with Planning prior to 0 MAJOR 0 SANITARY SEWER DISTRICT
submittal of Building Permit application.
0 ENVIRONMENTAL HEALTH
BldgApp_2011.doc revised 06/21/11