B-2017-0260CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS:
CONTRACTOR:
PERMIT NO: B-2017-0260
22321 CUPERTINO RD CUPERTINO, CA 95014-1043 (326 16 082)
PRESTIGE INC
SAN JOSE, CA 95134
OWNER'S NAME: GARDNER DEANE A AND FUJIMOTO SUSAN A TRUSTE
DATE ISSUED: 04/13/2017
OWNER'S PHONE: 408-203-6792
PHONE NO: (408) 221-8679
LICENSED On A TOR' DECLARATION
BUILDING PERMIT INFO:
License Class $ Lie. #943704
Contractor PRESTIGE INC Date 02/28/2018
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:
RECONFIGURE/REMODEL OF KITCHEN (300 SF) DINNING ROOM
I hereby affirm under penalty of perjury one of the following two declarations:
(106); AND DECK (580 SF)
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
fperformance of the work for which this permit is issued.
/2.' I have and will maintain Worker's Compensation Insurance, as provided for by
i Section 3700 of the Labor Code, for the performance ofthe work for which this
permit is issued.
Sq. Ft Floor Area:
Valuation: $566.00
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
32616 082
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 Cupertfrro-ankinst liabilities, judgments,costg-,-a�d expenses which
PERMIT EXPIRES IF WORK IS NOT STARTED
may accrue against QQ City in consegLp�nce"of the granting of this permit.
Addition( Ily he " ri pdersta Sand will comply with all non -point
'i
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
source r la io pe Gu , o Municipal Code, Section 9.18.
180 DAYS FROM LAST CALLED INSPECTION.
Signature ) Date 4/13/2017
Issued by: Abby Ayende
Date: 04/13/2017
OWNER-BLlii DER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of the
RE -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)
2. I, as owner of the property, am exclusively contracting with licensed
Signature of Applicant:
contractors to construct the project(Sec.7044, Business & Professions Code).
Date: 4/13/2017
I hereby affirm under penalty of perjury one of the following three declarations:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
m. 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 b the -Bay Area Air Qualls anagement District I
Worker's Compensation laws of California. If, after making this certificate of
will maintain compliance he uric lino Municipal Code, Chapter 9.12 and
exemption, I become subject to the Worker's Compensation provisions of the
the Health & S fe Cod ons 25505, 5533, and 2$534.
Labor Code, I must forthwith comply with such provisions or this permit shall
- ='
be deemed revoked.
Owner or authorized agent.
APPLICANT CERTIFICATION
Date: 4/13/2017 �l
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
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
1 understand my plans shall be used as public records.
Code, Section 9.18.
Licensed
Signature Date 4/13/2017
Professional
CONSTRUCTION- PERMIT APPLICATION
COMMUNITY DEVELOPMENT -DEPARTMENT • BUILDING DIVISION
1 D300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228 • FAX (408) 777.3333 • bLlildino cuoe ino,pg .J? %� }}�
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By rlry signature below, I certify to each of the following: 1 am the proper[), owner or autYlorized to act on The proper), owner's behalf. I have read this
application and the information I have provided is cen'ect. I have read the Description of t�Jork and verify it is accurate. I agree to comply with all applicable Iocai
ordinances and state laws relatinyg to building ruction. I authorize yepreseutEtives of Cupertino to enter the above -identified property for inspection purposes,
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Signature ofApplicalt?Agent; v' � Date.
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