B-2016-2530CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS:
10131 ALHAMBRA AVE CUPERTINO, CA 95014-1203 (326 23 027)
CONTRACTOR:
J B S CONSTRUCTION
PERMIT NO: B-2016-2530
SARATOGA, CA 95070
OWNER'S NAME:
DATE ISSUED: 03/30/2017
OWNER'S PHONE:
PHONE NO: (408) 390-5577
LICENSED CONTRACTOR'S DECLARATION
BUILDING PERMIT INFO:
License Class B Lic. #980527
Contractor,) B S CONSTRUCTION Date 91/31!2019
X BLDG _ELECT —PLUMB
I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing
— MECH X RESIDENTIAL — COMMERCIAL
with Section 7000) of Division 3 of the Business & Professions Code and that my
license is in full force and effect.
JOB DESCRIPTION:
I hereby affirm under penalty of perjury one of the following two declarations:
CONSTRUCT NEW HOME (2151 S.F.); ATTACHED GARAGE (428 S.F.)
NEW PORCH (36 S.F.)
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
� 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: 2579
Valuation: $400000.00
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above
APN Number:
Occupancy Type:
information is correct. 1 agree to comply with all city and county ordinances
and state laws relating to building construction, and hereby authorize
326 23 027
R-3 (Custom),R-3 (Custom),U (Private Gar /Ag Bldg),U
representatives of this city to enter upon the above mentioned property for
(Private Gar/Ag Bldg)
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.
PERMIT EXPIRES IF WORK IS NOT STARTED
Additionally, the applicant understands and will comply with all non -point
source regulations per the Cupertino Municipal Code, Section 9.18..
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
Signature( Date 3-30-2017
Issued by: Kim Dunbar
OWNER -B 1iI D R DECLARATION
Date: 03/30/2017
I hereby affirm that I am exempt from the Contractor's License Law for one of the
following two reasons:
RE -ROOFS:
1. I, as owner of the property, or my employees with wages as their sole
All roofs shall be inspected prior to any roofing material being installed. If a roof is
compensation, will do the work, and the structure is not intended or offered for
installed without first obtaining an inspection, I agree to remove all new materials for
sale (Sec.7044, Business & Professions Code)
inspection.
2. I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec.7044, Business & Professions Code).
Signature of Applicant:
Date: 3-30-2017
I hereby affirm under penalty of perjury one of the following three declarations:
t. I have and will maintain a Certificate of Consent to self -insure for Worker's
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
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
HAZARDOUS MATERIALS DISCLOSURE
Section 3700 of the Labor Code, for the performance of the work for which this
I have read the hazardous materials requirements under Chapter 6.95 of the
permit is issued.
California Health & Safety Code, Sections 25505, 25533, and 25534. I will
3. I certify that in the performance of the work for which this permit is issued, I
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
shall not employ any person in any manner so as to become subject to the
Health & Safety Code, Section 25532(a) should I store or handle hazardous
Worker's Compensation laws of California. If, after making this certificate of
material. Additionally, should I use equipment or devices which emit hazardous
air contaminants as defined by the Bay Area Air Quality Management District I
exemption, I become subject to the Worker's Compensation provisions of the
will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and
Labor Code, I must forthwith comply with such provisions or this permit shall
the Health & Safety Code, Sections 25505, 25533, and 25534.
be deemed revoked.
APPLICANT CERTIFICATION
Owner or authorized ager(t:f
I certify that I have read this application and state that the above information is
Date: 3-30-2017 "
correct. I agree to comply with all city and county ordinances and state laws
CONSTRUCTION LENDING AGENCY
relating to building construction, and hereby authorize representatives of this city
I hereby affirm that there is a construction lending agency for the performance
to enter upon the above mentioned property for inspection purposes. (We) agree
of work's for which this permit is issued (Sec. 3097, Civ C.)
to save indemnify and keep harmless the City of Cupertino against liabilities,
Lender's Name
judgments, costs, and expenses which may accrue against said City in
consequence of the granting of this permit. Additionally, the applicant understands
Lender's Address
and will comply with all non -point source regulations per the Cupertino Municipal
Code, Section 9.18.
ARCHITECT'S DECLARATION
understand my plans shall be used as public records.
Signature Date 3-30-2017
Licensed
Professional
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO: B-2016-2530
10131 ALHA.MBRAAVE CUPERTINO, CA 95014-1203 (326 23 027) JBS GREEN BUILDERS
INC
SARATOGA, CA 95070
OWNER'S NAME: DATE ISSUED: 03/30/2017
OWNER'S PHONE: PHONE NO: (408) 390-5577
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class a b,c-29 Lic. #980527
Contractor JBS GREEN BUILDERS INC Date 04/30/2019 X BLDG — ELECT — PLUMB
I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing _
MECH X RESIDENTIAL — COMMERCIAL
with Section 7000) of Division 3 of the Business & Professions Code and that my
license is in full force and effect. JOB DESCRIPTION:
I hereby affirm under penalty of perjury one of the following two declarations: CONSTRUCT NEW HOME (2151 S.F.); ATTACHED GARAGE (428 S.F.)NEW PORCH (36 S.F.)
1. I have and will maintain a certificate of consent to self-insure for Worker's DEF#1 - TRUSSES - ISSUED 12/18/18
Compensation, as provided for by Section 3700 of the Labor Code, for the
performance of the work for which this permit is issued.
Section 3700 of the Labor Code, for the performance of the work for which this
permit is issued. Sq. Ft Floor Area: 2579 Valuation: $400000.00
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: Occupancy Type:
and state laws relating to building construction, and hereby. authorize 32623046 R-3 (Custom),R-3 (Custom),U (Private Gar Ag Bldg),U
representatives of this city to enter upon the above mentioned property for (Private Gar /Ag Bldg)
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. PERMIT EXPIRES IF WORK IS NOT STARTED
Additionally, the applicant understands and will comply with all non-point WITHIN 180DAYS OF PERMIT ISSUANCE
source regulations per the Cupertino Municipal Code, Section 9.18. NCE OR
180 DAYS FROM LAST CALLED INSPECTION.
Signature Date 12/18/18
Issued by: Kim Dunbar
OWNER-BUILDER DECLARATION Date: 03/30/2017
I hereby affirm that I am exempt from the Contractor's License Law for one of the
following two reasons: RE-ROOFS:
1. I, as owner of the property, or my employees with wages as their sole All roofs shall be inspected prior to any roofing material being installed. If a roof is
compensation, will do the work, and the structure is not intended or offered for installed without first obtaining an inspection, I agree to remove all new materials for
sale (Sec.7044, Business & Professions Code)
inspection.
2. I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec.7044, Business & Professions Code). Signature of Applicant:
Date: 12/18/18
I hereby affirm under penalty of perjury one of the following three declarations:
1. I have and will maintain a Certificate of Consent to self-insure for Worker's ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
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 HAZARDOUS MATERIALS DISCLOSURE
Section 3700 of the Labor Code, for the performance of the work for which this I have read the hazardous materials requirements under Chapter 6.95 of the
permit is issued.
California Health & Safety Code, Sections 25505, 25533, and 25534. I will
maintain compliance with the Cupertino Municipal Code Chapter 9.12 a t
3. I certify that in the performance of the work for which this permit is issued I P P P p and he
' 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
Worker's Compensation laws of California. If, after making this certificate of air contaminants as defined by the Bay Area Air Quality Management District I
exemption, I become subject to the Worker's Compensation provisions of the will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and
Labor Code, I must forthwith comply with such provisions or this permit shall the Health & Safety
be deemed revoked.
APPLICANT CERTIFICATION Owner or authorized agent:
I certify that I have read this application and state that the above information is
Date: 12/18/18
correct. I agree to comply with all city and county ordinances-and state laws CONSTRUCTION LENDING AGENCY
relating to building construction, and hereby authorize representatives of this city I hereby affirm that there is a construction lending agency for the performance
to enter upon the above mentioned property for inspection purposes. (We) agree of work's for which this permit is issued (Sec. 3097, Civ C.)
to save indemnify and keep harmless the City of Cupertino against liabilities, Lender's Name
judgments, costs, and expenses which may accrue against said City in
consequence of the granting of this permit. Additionally, the applicant understands Lender's Address
and will comply with all non-point source regulations per the Cupertino Municipal
Code, Section 9.18. ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Signature Date 12/18/18 Licensed
Professional
NO FEE FOR RECORDING PURSUANT TO
GOVERl`ajENT CODE SECTION 27383
When Recorded Mail To:
City of Cuperino
Community Development Department
10300 Torre Avenue
Cupertino, CA 95014
24074764
Regina A b com+endras
Santa Clara County - Clerk -Recorder
12/04/2018 08:51 AM
Titles: I Pages: 3
Fee0:00
Taxs$0
Total: 0.00
1111 W.Aq C
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PROPERTY OWNER(S):
Owner's Sib atlzre
e
Print "Owner's Name
Date
CITY AlCT HORIZATION:
Ellen Yau Associa lanner
a
CWL9(;=®kP NHA ALL-PURPOSE ACKNOWLEDGMENT EDPMENT CIVIL CODE § 1189
A notary public or other officer completing this certificate verifies only the identity of the individual who signed the document
to which this certificate is attached, and not the truthfulness, accuracy, or validity of that document.
State of California`
County of 0"
On boy em 6c- before me, Lr;'it uvkc,^ Ja,LJ,,,- /�Acyr ,
Date Here InsertVNameand Title of We Officer
personally appeared U
Name(s) of Signer(s)
who proved to me on the basis of satisfactory evidence to be the ers n(s) whose (�(s)&are subscribed
to the within instrument and acknowledged to me that he/ e` they executed the same in his /their
authorize capac'�r(ies), and that by his�ier/the' siggn�nat�u��re;s) on the instrument th perso (s), or the entity
upon beh�ch,the ers�(s) acted, execute instrument.
I certify under PENALTY OF PERJURY under the
5�a,o LAURi;N SAPU®AR laws of the State of California that the foregoing
NotaryPublic- California Z paragraph is true and correct.
Z Santa Clara County
r *° Commission # 2247155
Aly Comm. E xxpires Jun 22, 2022 WITNESS my hand and official seal.
—64
Signature
Place Notary Seal and/or Stamp Above Signature of Notary Public
Completing this information can deter alteration of the document or
fraudulent reattachment of this form to an unintended document.
Description of Attached Document _
Title or Type of Document:
Document '11� Number of Pages:
Signer(s) Other Than Named Above:
Capacity(les) Clalmed by Signer(s)
Signer's Name:
❑ Corporate Officer — Title(s):
❑ Partner — ❑ Limited ❑ General
❑ Individual ❑ Attorney in Fact
❑ Trustee ❑ Guardian of Conservator
❑ Other:
Signer is Representing:
02017 National Notary Association
Signer's Name:
❑ Corporate Officer — Title(s):
❑ Partner — ❑ Limited ❑ General
❑ Individual ❑ Attorney in Fact
❑ Trustee ❑ Guardian of Conservator
❑ Other:
Signer is Representing:
I I I
A notary public or other officer completing this
certificate verifies, only the identity of the individual
who signed the document to which this certificate is
attached, and notthetruthfulness, accuracy, or
validity of that document.
State of California
County of '
On f � before m e, C -��1/�Z-I e-_
(insert name and title of the officer)
personally appeared 4-Z- 1 IV41&1:f I M
who proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/are
subscribed to the within instrument and acknowledged to me that hb/she/they executed the same in
his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the
person(s), or the entity upon behalf of which the person(s) acted, executed the instrument.
I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing
paragraph is true and correct.
WITNESS my hand and official seal.
Signatu re (SeaQ
GSl',GH.
Notary Piitalic , ftoen6i6
sata MraXog
..aty, z
Comhliggion #212-16.52
My Comm, Expires 9