7644CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO: B-2017-0392
7544 KIRWIN LN CUPERTINO, CA 95014-4337 (359 23 001) LEISURE LIFE WALK
IN TUBS AND
SHOWERS
GOLD RIVER, CA
OWNER'S NAME: HALL ROBERT B AND SHIRLEY A TRUSTEE I I DATE ISSUED: 03/09/2017 1
OWNER'S PHONE: 408-253-7026 1 1 PHONE NO: (916) 526-8333
LICENSED CONTRACTOR'S DECLARATION
License Class B Lic. #956300
Contractor LEISURE LIFE WALK IN TUBS AND SHOWERS Date 01/31/2019
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. 1 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.
j 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
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.
i
Signature Date 03-09-2017
OWNFR-BUUDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of the
following two reasons:
a. 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).
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.
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.
s. 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,
Signature Date 03-09-2017
BUILDING PERMIT INFO:
BLDG X ELECT X PLUMB
MECH X RESIDENTIAL _ COMMERCIAL
JOB DESCRIPTION:
REPLACE EXISTING TUB ADD GFI
Sq. Ft Floor Area: I Valuation: $5000.00
APN Number: Occupancy Type:
359 23 001
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
Issued by: Kim Dunbar
Date: 03/09/2017
R&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: 03-09-2017
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,. S tions 25505 25533, and 25534.
r
Owner or authorized agent:
Date: 03-09-2017
C STRUCIUN 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
Lenders Address
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Licensed
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE CUPERTINO, CA 95014-3255
(408) 777-3228 • FAX (408),777-3333 • building9cupertino.orrc
LJ NEW CONSTRUCTION ❑ ADDITION �� L 4 v
❑ALTERATION ALTERATION/Tl ❑ REVISION/ DEFE D ORIGINAL PERMIT # .
PROJECT ADDRESSI
APCid
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O A PHONE � E-MAIL
STREET ADDRESS ' CITY, STATE, Z,IP FAX
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CONTACT /NAME P(T�jjON%E�
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El OWNER ❑' OWNER -BUILDER ❑ OWNER.AGENT CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑: TENANT
CONTRACTOR AME LIClrNSE �R > LICENSE E BUS. LIC # F
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CqMPANYNAME L FAX
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ARCHITECTIENGINEER NAME ✓ V 4 LICENSE NUMBER BUS. LIC #
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY, STATE, ZIP PHONE
DESCRIPTION OF WORK �
EXISTING USE
PROPOSED USE
CONSTR. TYPE
# STORIES
I
USE
TYPE
OCC.
SQ.FT.
VALUATION ($)
EXISTG
NEW
FLOOR
DEMO
TOTAL
AREA
AREA
AREA
NET AREA
v (J
BATHROOM
FMCHEN -
OTHER
REMODEL AREA
I REMODEL AREA.
REMODEL AREA
# DWELLING UNITS: IS A SECOND UNIT ❑ YES SECOND STORY ❑ YES
BEING ADDED? ❑ NO ADDITION? []NO
PRE -APPLICATION ❑ YES IF YES, PROVIDE COPY OF IS THE BLDG AN ❑ YES ' REC D - TOTAL VALUATION:
PLANNING APPI, # ❑ NO PLANNING APPROVAL LETTER EICHLER HOME? ❑ NO n !'
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 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 b ding construction.. I authorize representatives of Cupertino to enter the abov ide tifred property for inspection purposes.
Signature of Applicant/Ager r Date:
SUPPLEMENTAL INFORMATION REQUIRED .
_ New SFD or Multifamily dwellings: Apply for demolition permit for
existing building(s). Demolition permit is required prior to issuance of building
permit for new building.
—Commercial Bldgs: Provide a completed Hazardous Materials Disclosure
form if any Hazardous Materials are being used as part of this project.
Copy of Planning Approval Letter or Meeting with Planning prior to
submittal of Building Permit application.
BldgApp 201 Ldoe revised 06121111