B-2017-0589CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO: B-2017-0589
10248 WILL CT CUPERTINO, CA 95014-2224 (316 25 020) BROTHERS HOME
IMPROVEMENT INC
ROCKLIN, CA 95765
OWNER'S NAME: FORTES GERALD RAND JOSEPHINE F TRUSTEE I (DATE ISSUED: 04/13/2017
OWNER'S PHONE: 650-280-6965 I I PHONE NO: (916) 791-9170
l_ 1X4143a RUI# LU14.2PI-XIIATUA, V tole
License Class -17 Lic. #699009
Contractor BROTHERS HOME IMPROVEMENT INC Date 11/30/2018
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:
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
Cj� performance of the work for which this permit is issued.
i` 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 perms Cupertino Municipal Code, Section 9.18.
Signature Date 4/13/2017
OWNER-BUIEDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of the
following two reasons:
i. 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. I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec.7044, Business & Professions Code).
PERMIT INFO:
X BLDG —ELECT —PLUMB
_ MECH X RESIDENTIAL ^ COMMERCIAL
JOB DESCRIPTION:
REPLACE WINDOWS (6) - LIKE FOR LIKE TO MEET EGRESS;
REPLACE PATIO DOORS (2)
Sq. Ft Floor Area: I Valuation: $7336.00
APN Number: Occupancy Type:
316 25 020
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
Issued by: AbbA, pnde
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.
Signature of Applicant:
Date: 4/13/2017
I hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS "A"
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.
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 Date 4/13/2017
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 Cod _ 505, 25533, and 25534.
Owner or authorized agent:
Date: 4/13/2017
CONSTRUCTION LEN ING 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
ran
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CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT - BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228 • FAX (408) 777-3333 • buildinciL@cupertino.org
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PROJECT ADDRESS 107 `
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OWNER NAME
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❑ OWNER ❑ OWNER -BUILDER ❑ OWNERAGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME
LICENSE NUMBER
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LICENSE LICENSE TYPE ®% //�
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BUS. LIC # 2190
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BUS. LIC #
COMPANY NAME
E-MAIL
FAX
STREET ADDRESS
CITY, STATE, ZIP
PHONE
DESCRIPTION OF WORK
EXISTING USE
PROPOSED USE CONSTR.
TYPE
# STORIES
1
USE
TYPE
OCC.
SQ.FT.
VALUATION ($)
EXISTG
AREA
NEW FLOOR
AREA
DEMO
AREA
TOTAL
NET AREA
BATHROOM KITCHEN
REMODELAREA REMODELAREA
OTHER
REMODELAREA
-
PORCH AREA
DECK AREA
TOTAL DECK/PORCH AREA
GARAGE AREA: DETACH
-
❑ ATTACH
#DWELLING UNITS:
IS A SECOND UNIT OYES
SECOND STORY ❑YES
BEING ADDED? ❑NO
ADDITION? [:]No
PRE -APPLICATION []YES IF YES, PROVIDE COPY OF
PLANNINGAPPL# []NO PLANNING APPROVAL LETTER
IS THE BLDG AN ❑ YES
EICHLER HOME? NO
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TOTAL VALUATION:
73311 .�
By my signature below, I certify to each of the following: I am the property owner or authorized agent to act on thelproperty owner's behalf. I have read this
application and the information I ha v e ' orrect. 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 t b ; g c ction. I authorize representatives of Cupertino to enter the above -idef �tifiedd rropperty for inspection purposes.
Signature of Applicant/Agent:
Date:
SUPPLEME TAL ORMATION REQUIRED
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New SFD or Multifamily dwellings: Apply for demolition permit for
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existing building(s). Demolition permit is required prior to issuance of building
permit for new building.
C�'EICP'RES3.
:Q':;:P'LANNtPi�'FLAtY+VIE_
Commercial Bldgs: Provide a completed Hazardous Materials Disclosure
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form If any Hazardous :Materials are being used as part of this project.
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Copy of Planning Approval Letter or Meeting with Planning prior to
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submittal of Building Permit
g application.
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BldgApp_2011.doc revised 06121/11