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B-2017-0516CITY OF CUPERTINO BUILDING PERMIT I BUILDING ADDRESS: 20637 CRAIG CT CUPERTINO, CA 95014-2912 (359 15 014) OWNER'S NAME: HAVILAND JOHN L AND MARILYNNE E TRUSTEE OWNER'S PHONE: 408-497-7521 LICENSED CONTRACTOR'S DECLARATION License Class St$ Lic. # 76 7116 Contractor AVALON STRUCTURAL INC Date 09/30/2017 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. 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 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 regulatio s per%tthe Cupertino Municipal Code, Se 9.18. Signat6fito - -2017"' I hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: 1. 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). CONTRACTOR: PERMIT NO: B-2017-0516 AVALON STRUCTURAL INC APTOS, CA 95003 DATE ISSUED: 03/30/2017 PHONE NO: (831) 4794389 BUILDING PERMIT INFO: X BLDG —ELECT —PLUMB _ MECH X RESIDENTIAL _ COMMERCIAL JOB DESCRIPTION: REPAIR FOUNDATION CUPERTINO BUS LIC -403088 03/29/2018 WC CERT ATTACHED Sq. Ft Floor Area: I Valuation: $16720.00 "N Number: Occupancy Type: 359150 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: 03/30/2017 RF 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: 03-30-2017 I hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF 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. 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. 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, "A" OR BETTER 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 9.1 an the Health & Safety Code, Sections 25505, 25533, and 25534. Owner or authorized age Date: 03-30-2017 � CONSTR TION 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 Date 03-30-2017 Professional CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 CUPERTIN© I (408) 777-3228 • FAX (408) 777-3333 • building cupertino.org ❑ NEW CONSTRUCTION ❑ ADDITION ALTERATION / TI ❑ REVISION / DEFERRED ORIGINAL PERMIT # PROJECT ADDRESS ®(_ 5-1 r APN # S- ,p Ery d OWNERNAME I n,^ I V1 -T a„ PHONE �JfX ®�L��-�C E-MAIL STREET ADDRESS (jYQ f CITY, STATE, ZIP G (L�J/ � ;'I/T% &A CONTACT NAME ^ Pa PHONE Q 1 `Z�7 b' R Gy E-MAIL �� ��a �� STREET ADORES$ y�17y.1� CITY, STATE, ZIP /� C FAX I � �❑ ❑ OWNER/�. OWNER BUILDER ® OWNER AGENT CONTRACTOR El CONTRACTOR AGENT ® ARCHITECT ❑ ENGINEER ® DEVELOPER ❑ TENANT CONTRACTOR NAME Pa LICENSE NUMBER / _-7 -7 I j ( `�CJ { i {p LICENSE TYPE 42/ BUS. COMPANYNAME A , O� 1 �, 1 ,ni J 5 .vai ,n �, V i'"ljY ! �j"f-/ I.T.(9fw1 ` E-MAIL STREET ADDRESS ' ry Vj , vin - _ / ' � /+ I • n CITY, S TATE, ZIP n /� /� Rs � PHONE ARCHITECTGINE �NC✓I i1.I 1 l / LICENSE NUMBER �1 '% c ` `�J`,�G BUS. LIC # COMPANY NAME ✓,0v PA -IV -61n &d� l v� FAX V C E-MAIL blobv)�y A� / STREET ADDRESS CITY, STATE, ZIP �"�� ` n �y �,JC (� 9 ^ "-7 PHONE � clan DESCRIPTION OF WORKc LL \ �J -'I n Wi sin r� n Ing EXISTINGUSE PROPOSED USE CONSTR. TYPE # STORIES USE TYPE OCC. SQ.FT. VALUATION ($) EXISTG AREA NEW FLOOR AREA DEMO AREA TOTAL NET AREA BATHROOM REMODEL AREA KITCHEN REMODEL AREA OTHER REMODEL AREA PORCH AREA DECK AREA TOTAL DECKIPORCH AREA GARAGE AREA:CIDETACH ❑ ATTACH # DWELLING UNITS: IS A SECOND UNIT ® YES BEINGADDED? ®NO SECOND STORY ❑YES ADDITION? ®NO PRE -APPLICATION []YES IF YES, PROVIDE COPY OF PLANNING ADPL # ®NO PLANNING APPROVAL LETTER IS THE BLDG AN 0 YES EICHLER HOME? ®NO RE B TOTAL VALUATION: "7 o By my signature below, I certify to each of the following: I am the property owner or authorized 4gent to act on the property owner's behalf. I have read this application and the information I have provi 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 bui 'n cons . I authorize re rese tatives of Cupertino to enter the above -identified property for inspection purposes. Signature of Applicant/Agent: A % ZWM / Date: 7 SUPPLENffi,IqTAL INFORMATION REQUIRED PLAN CHECK TYPE ROUTING SLIP ❑ OVFR-THF-COUNTER ❑ BUILDING PLAN REVIEW _ 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. ❑ EXPRESS ❑ PLANNING PLAN REVIEW —Commercial Bldgs: Provide a completed Hazardous Materials Disclosure ElSTANDARD 171PUBLIC 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 ❑ MAJOR ❑ SANITARY SEWER DISTRICT submittal of Building Permit application. ❑ ENVIRONMENTAL HEALTH BldgApp_2011.doc revised 06/21/11 ,ACCPR17® CERTIFICATE OF LIABILITY INSURANCE �.�1 DATE (..MDNYYY) 09/21/2016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Christina Prinz PRINZ INSURANCE SERVICES 9035 Soquel Avenue' Suite 105 PHOE FAX A/c,NNo, Ext): (831) 475-4091 (AJC, No): (831) 475-4042 ADDRIESS: sales@ca-ins.com PRODUCER CUSTOMER ID #AVALO0OOOO1 INSURER(S) AFFORDING COVERAGE MAIC Santa Cruz CA 95062-2033 INSURED INSURER A :Benchmark Insurance Company Avalon Structural, Inc. INSURER B :Inte on Preferred Insurance CO. 31488 18.1 Ridgeview Drive INSURER C .California Insurance Company 38865 INSURER D -- INSURER E / / Aptos CA 95003-2714 INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. lNSR LTR TYPE OF INSURANCE ADDL lNSR R WVD POLICY NUMBER POLICY EFF (MWDDNYYY) POLICY EXP (MM/DDNYYY) LIMITS A GENERAL LIABILITY BICS014378 5/12/2016 05/12/2017 EACH OCCURRENCE $ 1,000'000 DAMAGE TO RENTED 5O PREMISES Ea occurrence $ 000 X COMMERCIAL GENERAL LIABILITY / / / / MED EXP (Any one person) $ 5,000 CLAIMS -MADE U OCCUR ! / ! / PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 ! / / J GE AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 2,000,000 $ X POLICY PRO LOC ! ! ! ! B AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS 002633774-02 4/05/2016 ! / / ! 4/05/2017 ! ! COMBINED SINGLE LIMIT $ 750,000 (Ea accident) BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ $ X , NON -OWNED AUTOS ! ! ! ! $ UMBRELLA LIAROCCUR / / / ! EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAR HCLAIMS-MADE / ! ! / DEDUCTIBLE $ ! ! ! ! $ RETENTION $ ! ! ! ! WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNERlFJCECT Y / N OFFICER/MEMBER EXCLUDED? ® (Mandatory In NH) N/A I 46-871481-01-04 5/13/2016 / ! / / 05/13/2017 / / ! ! X WC STAMTIU- OTRH- E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYEH $ 1,000,000 E.L. DISEASE - POLICY LIMIT I $ 1.000.000 If yes, describe under DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) r4 A— u^1 n=® CANCELLATION %,ePL ur!%1M 1 G nve..vc.-. CANCELLATION ACORD 25 (2009/09) @ iris-zuua Auurtu L urtrl.JnA l iu1V. A11 r,911- 16561 V INS025 (zoosos) The ACORD name and logo are registered marks of ACORD -----• - • -- - - (925),639-4209( Attri L Derald ) - Clearwater SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS, D. Clearwater Construction AUTHORIZED REPRESENTATIVE PO Box 801 Clayton CA 94517- .a ACORD 25 (2009/09) @ iris-zuua Auurtu L urtrl.JnA l iu1V. A11 r,911- 16561 V INS025 (zoosos) The ACORD name and logo are registered marks of ACORD Bob Patterson, P.E. 17953 Berta Canvon Rd. Salinas. CA 93907 >a : rrLI z LIM 20637 Craig Ct. Cupertino CA Project address 20637 Craig Ct. Cupertino CA References S I by Avalon dated March 29, 2017 approved b} Patterson & Associates Dear Ms. Tan, I have inspected the rebar and stemwall repair performed by Avalon Structural, and find it to be in conformance with the above referenced construction detail which was approved by me. I recommend approval by the City inspector, with permission to place concrete. Yours Truly. i Ro ert Patterson, P.E. C30755 ti� 7-1