B-2017-0484f
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS:
CONTRACTOR:
PERMIT NO: B-2017-0484
19088 STEVENS CREEK BLVD CUPERTINO, CA 95014 (375 07 046)
FORESITE
CONSTRUCTION INC
ELK GROVE, CA 95624
OWNER'S NAME: UNITED POLARIS LLC
DATE ISSUED: 03/29/2017
OWNER'S PHONE: 408-965-8798
--lPHONE
NO: (916) 509-3444
LICENSED CONTRACTOR'S DECLARATION ATION
BUILDING PERMIT INFO:
License Class 5 Lic. #1001276
Contractor FORESITE CONSTRUCTION INCDate 04/30/2019
X BLDG —ELECT _PLUMB
I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing
MECH _ RESIDENTIAL X COMMERCIAL
with Section 7000) of Division 3 of the Business & Professions Code and that my
license is in full force and effect.
JOB DESCRIPTION:
HILTI; T.I. - RETAIL; REPAIR WALL DAMAGE (200 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
performance of the work for which this permit is issued.
I have and will maintain Worker's Compensation Insurance, as provided for by
1 Section 3700 of the Labor Code, for the performance of the work for which this
permit is issued.
Sq. Ft Floor Area:
Valuation: $10000.00
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above
APN Number:
Occupancy Type:
information is correct. I agree to comply with all city and county ordinances
and state laws relating to building construction, and hereby authorize
375 07 046
B (Tenant Improvements)
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 applica� stand nd will comply with all non-point
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
source regulations p tr' he Cup rtin unic� I Code, Section 9.18.
180 DAYS FROM LAST CALLED INSPECTION.
Signature Date 3/29/2017
Issued by: Abby Ayende
Date: 03/29/2017
I hereby affirm that I am exempt from the Contractor's License Law for one of the
R& ROOFS:
following two reasons:
All roofs shall be inspected prior 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 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)
z. I, as owner of the property, am exclusively contracting with licensed
Signature of Applicant:
contractors to construct the project (Scc.7044, Business & Professions Code).
Date: 3/29/2017
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.
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 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: 3/29/2017
1 certify that I have read this application and state that the above information is
CONSTRUCTION LENDING AGENCY
correct. I agree to comply with all city and county ordinances and state laws
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 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
ARCHITECT'S DECLARATION
Code, Section 9.18.
1 understand my plans shall be used as public records.
Licensed
Signature Date 3/29/2017
Si g
Professional
1
CUPERTINO
NEW CONSTRUC
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE - CUPERTINO, CA 95014-3255
(408) 777-3228 • FAX (408) 777-3333 • buildir cupertino.orq
CION Q ADDITION W ALTERATION / TI ❑ REVISION/ DEFERRED ORIGINAL PERMIT #
PROJECT ADDRESS ' APN#
OWNERNAME PHONEE MAIL
STREET ADDRESS CITY, STATE, ZIP
FAX
CA
CONTACT NluVI
PHONE E-MAII
ra
STREETADDRFrSS �)
CITY, Ft:,'m
FAX
4
�-
❑ OWNER ❑ OWN40"-B ER ❑ OWNERAGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ENGINEER ❑ DEVELOPER ❑ TENAYvx
CONTRACT,rglajN ME C�LICENSENUMBER 2IVO7
LICENSETYPEiB
BUS. LIC
►�N
COMPANY
E-MAIL
FAX
STREET ADDRESS i+� ,,,.�. CIT STATE ,ZIP
Px .
�
ARCHi'rECTIFNGINEERNAME LICENSE NUMBER
BUS. LIC #
COMPANY NAME E-MAIL �
I
---- ---�I
FAX
STREET ADDRESS CITY, STATE, ZIP
DESCRIPTION' OF tVORK
EXISTING USE
PROPOSED USE - CONSTR. TYPE # STORIES
USE
TYPE
OCC.
SQ.FT.
VALUATION (�)
EXISTG NEWFLOOR DEMO - TOTAL
AREA AREA AREA NET AREA
BATHROOM
KITCHEN
OTHER
REMODEL AREA
REMODEL AREA
REMODEL AREA
PORCH AREA
DECK AREA TOTAL DECKNORCH AREA GARAGE AREA: DETACH
'
❑ ATTACH
I
# DWELLING UNITS:
IS A SECOND UNIT ❑ YES
SECOND STORY [] YES
'
'
BEING ADDED? IWO
"
ADDITION? TO
PRF, -APPLICATION ❑ YES IF YES, PROVIDE COPY OF
IS THE BLDG AN ❑ YES
REEKED 13Y'
TOTAL VALUATION:
PLANNING APPL # El NO PLANNING APPROVAL LETTER
HLER HOME? y�iQ0
_�"
'- v` I
orized agent act o the property owner's behalf. 1 have read this
By my signature below, I certify to each of the folio am th p�Description
application and the information I have provided is ect d have reaork and verify it is accurate. I agree to mply with all applicable local
ordinances and state laws relating to buildin ction. upertino to enter the above-' entified opefor inspection purposes.
Signature of Applicant/Agent: ® Date:
SUPPLEMENTAL IN RMATI0N QUIRED
PLAN CaEC TYPE
ROUTING SLIP
❑ OVEx THE COUNTEx
❑. BUILDING PLAN REVIEW
_ New SFD or Multifamily dwel gs: Apply for demolition permit for
existing building(s). Demolition p, rmit 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.
❑ LARGE
❑ FIRE DEPT
_ Copy of Planning Approval Letter or Meeting with Planning prior to
❑ MAdOR
ElSANITARY SEWERDISTRICT
submittal of Building Permit application.
❑ ENVIRONMENTAL HEALTH
B1dgApp_2011,doc revised 06/7.1/11
Im