B-2017-0458CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS:
11812 TRINITY SPRING CT CUPERTINO, CA 95014-5146
CONTRACTOR:
PERMIT NO: B-2017-0458
(366 53 045)
J S MILLER
CONSTRUCTION INC
CUPERTINO, CA
95015-0292
OWNER'S NAME: LI TOMI T AND TERESA H TRUSTEE
DATE ISSUED: 04/26/2017
OWNER'S PHONE: 4089960946
PHONE NO: (408) 446-1407
LICENSED CONTR TOR'S DECLARATION
BUILDING PERMIT INFO:
License Class B Lic. #899728
Contractor,! S MILLER CONSTRUCTION INCDate 47/31/2017
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:
KITCHEN REMODEL (200 SF); REMOVE WALL AND INSTALL
m. I have and will maintain a certificate of consent to self -insure for Worker's
BEAM BETWEEN KITCHEN/DINING ROOM; 1 ST FLOOR BATH
Compensation, as provided for by Section 3700 of the Labor Code, for the
REMODEL (35 SF); REPLACE ALL WINDOWS ON FIRST FLOOR (6
TOTAL).
performance of the work for which this permit is issued.
have
and will maintain Worker's Compensation Insurance, as provided for by
Section 3700 of the Labor Ct, for the performance of the work for which this
11
permit is issued.
Sq. Ft Floor Area:
Valuation: $30000.00
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above
APN Number:
Occupancy Type:
information is correct. I agree to comply with all city and county ordinances
and state laws relating to building construction, and hereby authorize
366 53 045
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 Cod ,Section 9.18.
180 DAYS FROM LAST CALLED INSPECTION.
Signature / OaC04 /26/2017
(r-7
Issued by: PAUL O'SULLIVAN
4 y "I
Date: 04/26/2017
OWWER-BUIELDERDECLARAT16N/
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
m. 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 (See.7044, Business & Professions Code).
Date: 04/26/2017
I hereby affirm under penalty of perjury one of the following three declarations:
m. 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.
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
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
will maintain compliance with the Cupertin°\yunicipal Code, Chapter 9.12 and
exemption, I become subject to the Worker's Compensation provisions of the
the Health & Safety Cade, ections 25-505,4533, and 25534.
Labor Code, I must forthwith comply with such provisions or this permit shall
F
be deemed revoked.
Owner or authorized agent: f
APPLICANT CERTIFICATION
Date: 04/26/2017
I certify that I have read this application and state that the above information isAGENCY
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
Code, Section 9.18.
1 understand my plans shall be used as public records.
Signature Date 04/26/2017
Licensed
Professional
CONS, RUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
CUPERTINO (408) 777-3228 • FAX (408) 777-3333 •bui. Idina oil ertino.pr
t_I NEW CONSTRUCTION ❑ADDITION !) ALI'1.i2 r�TION 1 TI 0 _ REVISION.1-DEFERRED ORIGINAL PRRMrr 0
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PRE -APPLICATION ❑ YES IF YLIS, PROVIDE COPY OF
PLANNINOAPPLR 0 PLANNING APPROVAL LETTER
IS THS BLDG AN 11TES
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By toy signature bolow, I certify to each of the following: I am the property owner or authitizAl a•Veot o act on the property owner's^ behalf, I have read this
application and the infonnation1 have provided is con-ect. I have read the Description of Work and verify it is accurate. • I agree to comply with all applicable local
ordinances and state laws reiatiu ,&ing00nSt1uGyQtL I authorize representatives of Cupertino to enter the above -identified propertyforinspection purposes,-
Signatum of Applicant/AgentDate: � �— ---i '-`
SUPPLEMENTAL INFORMAT10kJ RE IH RED
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ENVIRt1NMENTAL.}IEALTH--::--::.--
B1dgApp_2011.doc revised 06121111
41
May 24, 2017
City of TAkVM Gvpc- (L1, t No
Building Division
Attn: Building Inspector
Subject: 11812 Trinity Spring Ct
Post to beam connection
by MHA Consulting Engineers Inc.
Dear Sir,
1623 Wright Avenue
Sunnyvale Ca 94087
Ph# : 408-735-1524
Fax: 408-733-1548
Due to the site condition, typical post cap PC can be substituted by CS14
Strap. We approve the connection by using CS14 strap.
If you have any questions please call.
Yours Sincerely,
MHA Consulting Engineers Inc.
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t i Exp. 12/31/18 j ,
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