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B-2017-0605CITY OF CUPERTINO BUILDING PERMIT m BUILDINGADDRESS: CONTRACTOR: PERMIT NO: B-2017-0605 803 KIM ST CUPERTINO, CA 95014-4322 (359 20 001) SIGURA CONSTRUCTION INC SANTA CLARA, CA 95050 OWNER'S NAME: PURCELL TERRANCE J AND CARLEEN F ET AL DATE ISSUED: 04/17/2017 OWNER'S PHONE: 408-446-0323 PHONE NO: (408) 492-1379 LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: License Class 5 Lic. #865155 Contractor SIGURA CONSTRUCTION INC Date 09/30/2017 X BLDG _ ELECT _PLUMB I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing X MECH 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: 1ST AND 2ND FLOOR RESTUCCO (650 S.F.); REPLACE WINDOW (3) I hereby affirm under penalty of perjury one of the following two declarations: - LIKE FOR LIKE TO MEET EGRESS 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. Sq. Ft Floor Area: Valuation: $35000.00 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 359 20 001 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 applicant understands and will comply with all non -point WITHIN 180 DAYS OF PERMIT ISSUANCE OR source. regulations per the Cupertino Municipal Code, Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION. SignatureT19 Date 4/17/_2017 Issued by: AbbyA ende Date: 04/17/2017 OWNER -BUILDER 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: 4/17/2017 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 s. 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: " ti L�ed� APPLICANT CERTIFICATION Date: 4/17/2017 1 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 CONSTRUCTION LENDING AGENCY 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 4/17/2017 Professional -� -�D D U 05 CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 • building Qkupertino.orp ❑ NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION / TI ❑ REVISION / DEFERRED ORIGINAL PERMIT # PROJECT YuDDRESS j ��e APN# ®cI)I OWNERNAME f Q P;IONE i �Ll0-;Z-3 7STREET E-MAII ADDRESSCITY.y STAmT,�E,,,�ZI 00, ck5-o 1 d r7`a® FAX CONTACT NAME PHONE &5� .4� E-MAIL-1?0'�� Yet o®f . '] ® fi➢?/L%4a�iJ�r !�s%�lT 4 ST ET ADDRESS CITY, STATE, ZIP FAX � -4 Ct-A `�A �A �l ate' � ❑ OWNER ❑ OWNER -BUILDER ❑ OWNERAGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER,, TENANT CONTRACTOR NAME •�° 6'+ LICENS LICENSE TYPE L5 /❑ BUS. LIC # COMPANYNAME„j• B E-MAIL C`6 �-+-%adaZi{CbVS-rx L'C'.r-Zee, FAX STREET ADDRESS gryoC) _ _ y� �y CITY, TATE, ZIP /��p PHONE '7 ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS. LIC # COMPANY NAME E -MAH, FAX STREET ADDRESS CITY, STATE, ZIP PHONE DESCRIPTION OF WORK A-?7-RoXa 65-0 OF .5-r( 44C® )ki; V�S tL 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 DECKIPORCH AREA GARAGE AREA: 0 DETACH []ATTACH I # DWELLING UMTS: IS A SECOND UNIT ❑ YES. SECOND STORY []YES BEING ADDED?❑NO ADDITION. []NO PRE -APPLICATION []YES IF YES, PROVIDE COPY OF IS THE BLDG AN ❑ YES EIVED BY'. TOTAL VALUATION: PLANNING APPL # ❑ NO PLANNING APPROVAL LETTER EICHLER HOME? ❑ NO �'�^uA""'” lus,m By my signature below, I certify to each of the following: I am the property owner or authorized agent to act oni the property owner's behalf. I have read this application and the information I have provided 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 building construction. I authorize representatives of Cupertino to enter the above -identified property for inspection purposes. Signature of Applicant/Agent: Date: SUPPLEMENTAL INFORMATION REQUIRED PLAN CHECICTYPE 70I 1NGSLA' Q ave TEI&COUNTER © BUILDING PLAN REVIEW _ New,')FD or Multifamily dwellings: Apply for demolition permit for existing building(s). Demolition permit is required prior to issuance of building permit fo new building. © E)WRESS ' ©_ PLANK& PLAN RIMEW _ Commercial Bldgs: Provide a completed Hazardous Materials Disclosure © 5TANOARU © PURT'ICw[ITW form if any Hazardous Materials are being used as part of this project. © LARGE q III tE DEPT . _ Copy of Planning Approval Letter or Meeting with Planning prior to © MAJOR © SANITAli,Y StWER DISTRICT submittal of Building Permit application. © ENVIRONMENTAL HEALTH BldgApp_201 Ldoc revised 06/21/11 I