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B-2017-0251I CITY OF CUPERTINO BUILDING PERMIT I 1B 912 PORTAL PLDING Z CUPERTINO, CA 95014-3364 (369 46 007) ' SAN N360 CA 95118 PERMIT NO: B-2017-0251 OWNER'S NAME: GRAHM CRUMB OWNER'S PHONE: 888-277-5580 LICENSED CONTRACTOR'S DECLARATION License Class @ Lie. #950805 Contractor RECON360 LLC Date 92/31/2018 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: 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. 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. K111120 _3RW&11 11110 Of 3_11 hereby affirm that I am exempt from the Contractor's License Law for one of the 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) 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: 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. 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. C APPLICANT ICANT 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. Signature Date 02!1312017 DATE ISSUED: 02/13/2017 NO: (408) 981-3695 BUILDING PERMIT INFO: BLDG —ELECT —PLUMB MECH X RESIDENTIAL _ COMMERCIAL JOB DESCRIPTION: REPAIR TWO (E) WINDOWS Sq. Ft Floor Area: Valuation: $5000.00 APN Number:I Occupancy Type: 369 46 007 PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTION. Issued by: Kim Dunbar 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. ture of Applicant: 02/13/2017 ALL ROOF COVERINGS TO BE CLASS "A" OR 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 Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Sections 25505, ;g33, and 25534. Owner or authorized agent: Date: 02/13/2017 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 I understand my plans shall be used as public records. Licensed Professional ❑ XTE'W CONSTRUCTION CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 • build inc(akupertino ora 7 ADT)TTT(-)N 141 ., T TL'D h Til1TT ! TT — -- - �,•, .� u t cvlaJvly D> r�xxrD ORMNALPEKMITn PROJECT ADDRESS Cl q pork Ick -2,q I 1- OWNER NA J�E 11 n C Vf 6'x'1 �` V VI j PHONE E-I,ZAII qSg -;?77 -S-S70 STREETADDPESS CITY; STATF, ZIP FAX E6/()� ^ CONTACT NAME �ry.- j V, � I PHO'\T'60-377-9 Vt t I 91�r. �j ( 7'h // J 1 (�!6 6 STREET ADDRESS CITY, STATE, ZIP f � �c�l✓Vl. 1d'I� �Gl S� C(4 - FAX ❑ OWNER ❑ OR'N'"7t.t-BL-II-DER ❑ 01�,TTERAGEI;T ❑ CONTRACTOR COATPACTOR.AGENT ❑ ARCHITECT ❑ ENGA'EER ❑ DEVELOPER ❑ TENA'N'T COIvTRACTORNAA4Ep LICENSE LICEhTSETI'PE[7, - 1`C�Sckr tiJ�� s` ® � BtiS.LIC� C01,4PANY NAMER u E -MASE Rc �� : ,_7).COM FAX _ STREETADDRESS 'ClNe . CITY, STATE, ZIP S GlY1 Cif' ''S -//V PHONE ARCHITECTIENGIN-EER. NAME I LICENSE NU ABER BUS, LIC COA4PAhYNAA4E —� I E-i'WL — -- FAX �e STREET.ADDRE-SS CITY, STATE, ZIP A ^ PHONE i DESCRIPTION OF 1�'ORK ct sk °Ww' C+r Siy�ua �s meed Sf�`c �^aw CjavcID F_XISUNTG USE- I PROPOSED USE CONSTR. TYPE = STORIES USE TYPE OCC. -- SQ.FT. VALUATION (S) EXISTG NEW FLOOR DE7`40 TOTAL AREA AREA AREA NET AREA BATHROOM KITCHEN OTHER - RF ODELAREA RF�40DELAREA REMODELAREA i PORCHAREA DECKAREA TOTALDECK:PORCHAREA GARAGE AREA: ❑DETACH ❑ATTACH Dl�'ELLLNG UNITS: JS A SECOND LTIT ❑ Y'ES SECOND STORY ❑ YES - BELNGADDED? ENO ADDITION? ❑NO PRE -APPLICATION TIO. []YES TF YES, PROVIDE COPi' OF PL.Ah?-LNGAPPL-- ❑NO PLN-\1NG.A-PPROVALLETTER IS THE BLDG .4N D YES £ICHLERHME? ❑ NO s� : REC � " _-- _ _ -- TOTAL VALUATION: _ G - C/ By my signature below, I certify to each of the following: I aru the property owner or authorzed agent to act on the property owner's behalf I have read this application and the information I have provided is colTect. I have read the Description of" 'ork and verity it is accurate. I agree to comply all applicable local ordinances and state laws relating to b _ ons tion. I authorize representatives of Cupertino to the above -identified property for inspection enter purposes, Sigiature of ApplicantlAgent: SUPPLEMENTAL INFORAZATIONTRF L PL3\_CAEChTiPE't=;;;rs- ;: - ;`x€;i: '<"::< -ROUTING SLIP_; New SFD or Multifamily d`vellings: Apply for demolition pen -nit for � o+EKi ❑ existing building s). Demolition pennit is required prior to issuance of building THE Co1�TER = BLTIIDI\GPL�� }2E+iET4 permit for new buildinla. - - Commercial Bldgs: Provide a completed Hazardous Materials Disclosure ❑ ST4tDARD ❑, PLBLICijORi�S form if any Hazardous Materials are being used as part of this_project. LARGEF TIP DEPT _ Copy of Planning Approval Letter or Meeting with Planning prior to ❑ AZ�JOR ❑: submittal of Building Permit application. -S4hITAR2 SE�iERDI�TRICT �% - ❑. ENN IRO131E T -A- L HEALTly. - - - BldgIpp_2011.doc revised 06121/11