B-2017-0366CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS:
CONTRACTOR:
PERMIT NO: B-2017-0366
20097 JOHN DR CUPERTINO, CA 950144414 (369 33 035)
OWNERBUILDER
OWNER'S NAME: THORNE DARLENE G TRUSTEE
DATE ISSUED: 04/28/2017
OWNER'S PHONE: 408-724-0409
PHONE NO:
LICENSED CONTRACTOR'S DECLARATION
BUILDING PERMIT INFO:
License Class Lic. #
Contractor OWNER/BUILDER Date
X BLDG X ELECT _ PLUMB
MECH X RESIDENTIAL COMMERCIAL
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.
JOB DESCRIPTION:
REMODEL KITCHEN (211 S.F.); REMODEL DOWNSTAIRS
I hereby affirm under penalty of perjury one of the following two declarations:
BATHROOM AND CREATE 1/2 BATH UNDER STAIRS (71 S.F.);
1. I have and will maintain a certificate of consent to self-insure for Worker's
REMODEL FAMILY RM & CREATE (N) BEDROOM (260 S.F.);
Compensation, as provided for by Section 3700 of the Labor Code, for the
REMODEL LIVING RM (284 S.F.); RELOCATE LAUNDRY TO
performance of the work for which this permit is issued.
GARAGE; RELOCATE & UPGRADE MAIN PANEL (200 AMP); ADD
z. I have and will maintain Worker's Compensation Insurance, as provided for by
(N) SUB PANEL (100 AMP); REMODEL UPSTAIRS BATHROOMS
Section 3700 of the Labor Code, for the performance of the work for which this
AND CLOSET (220 S.F.).
permit is issued.
REV #2 - ADD NEW SHEAR WALL AND TIE DOWN TO ORIGINAL
APPLICANT CERTIFICATION
SHEAR WALL - ISSUED 6-23-2017
1 certify that I have read this application and state that the above
REV #1 - FOUNDATION CHANGE - ISSUED 5/18/2017
information is correct. I agree to comply with all city and county ordinances
Sq. Ft Floor Area:
Valuation: $85000.00
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
APN Number:
Occupancy e:
p y Typ
City of Cupertino against liabilities, judgments, costs, and expenses which
369 33 035
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, Sectiop. 9.18.
PERMIT EXPIRES IF WORK IS NOT STARTED
Signature Da
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
_
�7r
180 DAYS FROM LAST CALLED INSPECTION.
OWNER- BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of the
Issued by: Kim Dunbar
following two reasons:
Date: 04/28/2017
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
RF: ROOFS:
sale (Sec.7044, Business & Professions Code)
All roofs shall be inspected prior to any roofing material being installed. If a roof is
t 2. I, as owner of the property, am exclusively contracting with licensed
installed without first obtaining an inspection, I agree to remove all new materials for
contractors to construct the project (Sec.7044, Business & Professions Code).
inspection.
I hereby affirm under penalty of perjury one of the following three declarations:
t. I have and will maintain a Certificate of Consent to self-insure for Worker's
Signature of Applicant:
Compensation, as provided for by Section 3700 of the Labor Code, for the
Date: 06-23-2017
performance of the work for which this permit is issued.
`n I have and will maintain Worker's Compensation Insurance, as provided for by
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
L / Section 3700 of the Labor Code, for the,performance of the work for which this
permit is issued.
HAZARDOUS MATERIALS DISCLOSURE
I certify that in the performance of the work for which this permit is issued, I
I have read the hazardous materials requirements under Chapter 6.95 of the
shall not employ any person in any manner so as to become subject to the
California Health & Safety Code, Sections 25505, 25533, and 25534. I will
Worker's Compensation laws of California. If, after making this certificate of
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
exemption, I become subject to the Worker's Compensation provisions of the
Health & Safety Code, Section 25532(a) should I store or handle hazardous
Labor Code, I must forthwith comply with such provisions or this permit shall
material. Additionally, should I use equipment or devices which emit hazardous
be deemed revoked.
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
APPLICANT CERTIFICATION
the Health & Safety Code, Secti6 is 25505, 25533, and 25534.
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
Owner or authorized agent:
relating to building construction, and hereby authorize representatives of this city
Date: 06-23-2017
to enter upon the above mentioned property for inspection purposes. (We) agree
CONSTRUCTION LENDING A
to save indemnify and keep harmless the City of Cupertino against liabilities,
=ENCY
I hereby affirm that there is a construction lending agency for the performance
judgments, costs, and expenses which may accrue against said City in
of work's for which this permit is issued (Sec. 3097, Civ C.)
consequence of the granting of this permit. Additionally, the applicant understands
Lender's Name
and will comply with all non-point source regulations per the Cupertino Municipal
Code, Section 9.18;
Lender's Address
Signatu ,� D e 06-23-2017
"`'
ARCHITECT'S DECLARATION
�z
I understand my plans shall be used as public records.
�J
CUPERTINO
❑ NEW CONSTRUCTION
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 REVISION #2..aB
(408) 777-3228 • FAX (408) 777-3333 • build in cu ertino.or
❑ ADDITION ❑ ALTERATION / TI REVISION /DEF RRED ORTC,TNAT PFRMTT
PROJECT ADDRESS
API n
OWNER NAME / '^ Ij PHONE
/v
�� E-MAIL �
'L (/IS a
!/r—�
STREET.ADDRFSS / CITY, STATE,
2 i/
FAX
,`1�D �Li1 r
Pei n
CO'N'NAME ME PHONE
E ,1, L
STREET .ADDRESS
CITY, STATE, ZIP
FAX
❑ OWNER 9/0'NER-BUILDER ❑ OVINERAGENT ❑ CONTRACTOR ❑CONTRACTOR.AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME
LICENSE NUMBER
LICENSE TYPE
BUS. LIC
COT,QANY NAME
E-NiAIL
FAX
STREET.ADDRESS
CITY, STATE, ZIP
PHONE
ARCHITECT/ENGINEER NAME LICENSE NUMBER
BUS. LIC #
COMPANY NAME E-AZAIL
FAX
STREET ADDRESS
CITY, STATE, ZIP
PHONE
DESCRIPTION OF WORK
ciY4� t�t1J� S"�iP�� t,✓
,1Z
EXISTING USE PROPOSED USE CONSTR. TYPE r STORIES
j
USE
TYPE
OCC.
SQ.FT.
V'ALL'ATION (S)
EXISTG
NEN FLOOR
DEA4o
TOTAL
AREA
AREA
AREA
NET AREA
BATHROOM
KITCHEN
OTHER
REMODEL AREA
REMODEL AREA
RENIODELAREA
PORCH AREA DECK AREA
TOTAL DECKPORCH ,4RE.A
GARAGE AREA: EIDETACH
ATTACH
I
DWELLING UNITS:
IS A SECOND UNIT ❑ YES
SECOND STORY ❑ YES
BELNGADDED? ANO
ADDITION? NO
PRE -APPLICATION ❑ YES IF YES; PROVIDE COPY OF
1S THE BLDG AN ❑ YES
RECE $
TOTAL VALUATION:
PLA1,71NLNGAPPL= [:]NO PLaN'NLNGAPPROVAL LETTER
EICHLERHOME? ❑NO
By my signature below, I certify to each of the following: I aril the property owner or authorized agent to act on the property owner's behalf. I have read this
application and the information I have pr ded 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 b ' di c tion. I authorize represen tives of Cupertino to enter the above -identified property for inspection purposes.
Signature of Applicant'Agent:
Date: � — %/ j � -�112
SUPP 'ENTAL lNIFORMATION REQUIRED
PLAN CHECK TYPE'
RoUrlNcSLIP
❑ o\ FR
❑
New SFD or Multifamily dwellings: Apply for demolition permit for
existing building s). Demolition pen -nit is required prior to issuance of building
y
-THE coLz:TER
BUH DING Pia\ IZE«En
permit for new building.
❑ 'EXPRESS
[3 PI L. PLAN REVIEW
_ COmnlerClal Bldgs: Provide a completed Hazardous Materials Disclosure
❑ STANDARD'
❑ PUBLIC \\'OAKS
fonn 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
_
submittal of Building Permit application.
❑LaIOR
❑ s\rraRrsEttFitnlsTRlcr° "
❑ E \\'IRONI,IEIT.kL ilEALTH
BldgApp_2011.doc revised 0612111
It
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS:
CONTRACTOR:
PERMIT NO: B-2017-0366
20097 JOHN DR CUPERTINO, CA 95014-4414 (369 33 035)
HOMEOWNER
BUILDER
OWNER'S NAME: THORNE DARLENE G TRUSTEE
DATE ISSUED: 04/28/2017
OWNER'S PHONE: 408-724-0409
PHONE NO:
LICENSED CONTRACTOR'S DECLARATION
BUILDING PERMIT INFO:
License Class Lic. #
Contractor HOMEOWNER BUILDER Date
X BLDG X ELECT —PLUMB
MECH X RESIDENTIAL COMMERCIAL
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.
JOB DESCRIPTION:
REMODEL KITCHEN (211 S.F.); REMODEL DOWNSTAIRS
I hereby affirm under penalty of perjury one of the following two declarations:
BATHROOM AND CREATE 1/2 BATH UNDER STAIRS (71 S.F.);
t. I have and will maintain a certificate of consent to self -insure for Worker's
REMODEL FAMILY RM & CREATE (N) BEDROOM (260 S.F.);
Compensation, as provided for by Section 3700 of the Labor Code, for the
REMODEL LIVING RM (284 S.F.); RELOCATE LAUNDRY TO
performance of the work for which this permit is issued.
GARAGE; RELOCATE & UPGRADE MAIN PANEL (200 AMP); ADD
z. I have and will maintain Worker's Compensation Insurance, as provided for by
(N) SUB PANEL (100 AMP); REMODEL UPSTAIRS BATHROOMS
Section 3700 of the Labor Code, for the performance of the work for which this
AND CLOSET (220 S.F.).
permit is issued.
1
=� �ueA 5l 1$ O—
APPLICANT ERTIFICATION
REV #1 -FOUNDATION CHANGE
I certify that I have read this application and state that the above
Sq. Ft Floor Area:
Valuation: $85000.00
information is correct. I agree to comply with all city and county ordinances
and state laws relating to building construction, and hereby authorize
APN Number:
Occupancy Type:
representatives of this city to enter upon the above mentioned property for
inspection purposes. (We) agree to save indemnify and keep harmless the
369 33 035
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.
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
Signature Date 5/18/2017
180 DAYS FROM LAST CALLED INSPECTION.
OWNER -BUILDER DECLARATION
Issued by ABBY AYENDE
I hereby affirm that I am exempt from the Contractor's License Law for one of the
Date: 04/28/2017
following two reasons:
t. I, as owner of the property, or my employees with wages as their sole
RF -ROOFS:
compensation, will do the work, and the structure is not intended or offered for
All roofs shall be inspected prior to any roofing material being installed. If a roof is
sale (Sec.7044, Business & Professions Code)
installed without first obtaining an inspection, I agree to remove all new materials for
z. I, as owner of the property, am exclusively contracting with licensed
inspection.
contractors to construct the project (Sec.7044, Business & Professions Code).
I hereby affirm under penalty of perjury one of the following three declarations:
Signature of Applicant:
t. I have and will maintain a Certificate of Consent to self -insure for Worker's
Date: 5/18/2017
i Compensation, as provided for by Section 3700 of the Labor Code, for the
performance of the work for which this permit is issued.
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
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
HAZARDOUS MATERIALS DISCLOSURE
permit is issued.
I have read the hazardous materials requirements under Chapter 6.95 of the
3. I certify that in the performance of the work for which this permit is issued, I
California Health & Safety Code, Sections 25505, 25533, and 25534. I will
shall not employ any person in any manner so as to become subject to the
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
Worker's Compensation laws of California. If, after making this certificate of
Health & Safety Code, Section 25532(a) should I store or handle hazardous
exemption, I become subject to the Worker's Compensation provisions of the
material. Additionally, should I use equipment or devices which emit hazardous
Labor Code, I must forthwith comply with such provisions or this permit shall
air contaminants as defined by the Bay Area Air Quality Management District I
be deemed revoked.
will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and
the Health & Safety Code, Sections 25505, 25533, and 25534.
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is
Owner or authorized agent:
correct. I agree to comply with all city and county ordinances and state laws
Q 44
Date: 5/18/2017
relating to building construction, and hereby authorize representatives of this city
CONSTRUCTION LF_.NDING AGENCY
to enter upon the above mentioned property for inspection purposes. (We) agree
I hereby affirm that there is a construction lending agency for the performance
to save indemnify and keep harmless the City of Cupertino against liabilities,
of work's for which this permit is issued (Sec. 3097, Civ C.)
judgments, costs, and expenses which may accrue against said City in
Lender's Name
consequence of the granting of this permit. Additionally, the applicant understands
and will comply with all non -point source regulations per the Cupertino Municipal
Lender's Address
Code, Section 8.
Signatur 5/18/2017
ARCHITECT'S DECLARATION
I understand my'plans shall be used as public records.
COs v��
N TRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
Lj
10300 TORRE AVENUE - CUPERTINO, CA 85014-3255
(408) 777-3228 • FAX (408) 777-3333 • build! noQcuDertino.ora
rCU P E RT i Pt O- ( 1� (3-z a / 9 _ 1 j
-1
I NIF\IJC.ONSTRUCTION I -1 I ADDITION I I ALTFRAT1nN1/TI 1 t-� I RF.VTvI0W11)FFFPPT:n nRIC-,TUAT TmTumrws!
PROJECT ADDRESS zoos, 7 �+o
`�Ji
(�
{ ANN � � f w � 045
I D J
I
OWTEP T..0.A3E �1�� .' ! Ef %� p
_ `t
STREET.ADDPESS 7M 0
Go/
-i/ Vt !'� ?I40 -NE E-MAIL '
¢o -724- ol�o� - Can3��3��ou�..• cam
CITY, STATE, ZIP 7� r �Dr I F4JC
CONTACT NAME It n f J `/he �
PHONM ^ ^�� �, f 51„ 0577.1 E-)%WL�tA M W 00
v��N
STREET ADDRESS ()nL�aJio/` ng aAter f y.} 3
I •�❑3
CITY, STATE, ZZItP:
n ' ^ �'
I +�I
FAX
OWNER ❑ O\\'IdER•BLTIMER ❑ OWNTR AGENT
COh7RACTOR ❑ C01.7R1CTOR A0r;?,T ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TETANT
CONTRACTOR NAME
LICENSE1\71J7✓BER LICENSETYPE
6US.LIC0
COMPAk7' NAME
ordinances and state laws relating to b ' g construction. I authorize representativ f Cupertino to enter the above -identified property for ipspection nu}noses.
E4AAIL.
FAX
STREET ADDRESS
OTHER
CITY, STATE, ZIP
PHONE.
.4RCHITECT/ENGINEERNAME
I
LICENSE NUIMBER
BUS. LIC.'
COMPAAYNAA4E/4�. �`q�_. ,. —
STREETADDRESS2j07 ✓ �==u,1rJ
?�3 d c>u►h tear l� #
�Y
EA4AIL C�„ Lan „ I Do cm
CITY, STATE, (,f (G t (�r
_G;erirw, q 5al'f
FAX -
PHONE
4�- -os7?
DESCp.IP7ION OF WORT:
G���AREA: D
,�_ L 's
FxISTG NEW FLOOR 0
AREA AREA
DEi.40
AREA
USE I' t i'PE I OCC•
SQ.F'P. ? VALUATION (S)
it D'WEL1.DdG UNITS: ISA S£COND MIT ij YES SECOND STORY []YES --T
BELNG ADDED? PO ADDITION? Til NO
•
73
AEA -Z1,7 0
Zo n
� .�47rr iS
By Ivy signature below, I certify to each of the following: I a7u the property Owner or authorized agen behalf. 1 have read this
application and the information I have provided is correct. 1 have read the Description of Work and verify it is accurate. 1 agree to Comply with all applicable local
BATHROOM
ordinances and state laws relating to b ' g construction. I authorize representativ f Cupertino to enter the above -identified property for ipspection nu}noses.
KITCHEN
OTHER
REMODF.LAREA
Z j
RF.1✓,OAFLAREA �•y'
M40DELAREA
PORI A �I
v–r,REA
New SFD or Multifamily dwellin;s: Apply for demolition penuit for�
TOTAL D RCH
r,REA
G���AREA: D
_
existing buildinsrW. Demolition pennit is required prior to issuance of buildlr,gIN,
I
a L;CLDCNGPLkA RF11£\1
�rlrt��
E,L'P
permit for new building.
I TACH
DEi.40
AREA
USE I' t i'PE I OCC•
SQ.F'P. ? VALUATION (S)
BldgApp_2011.doc rev sed 06121111
it D'WEL1.DdG UNITS: ISA S£COND MIT ij YES SECOND STORY []YES --T
BELNG ADDED? PO ADDITION? Til NO
•
PRE-APPLIC.A710*? • Q YES IF YES, PROVIDE COPY OFI IS THE BLDG ANN ;ES • /�; ))A�,�� ,��� TOTALy_\'ALU4TI0.N:
PLA.'`?,TANQAPPL: ❑NO Pl./L',".'L'`G.APPROV.ALLE77ER £1CHLERHOA4E7
� .�47rr iS
By Ivy signature below, I certify to each of the following: I a7u the property Owner or authorized agen behalf. 1 have read this
application and the information I have provided is correct. 1 have read the Description of Work and verify it is accurate. 1 agree to Comply with all applicable local
ordinances and state laws relating to b ' g construction. I authorize representativ f Cupertino to enter the above -identified property for ipspection nu}noses.
Si-gnatureof Applicant/Ageut: _ T t Date:
SUPPLEMENTAL INFORMATION REQUIRED
New SFD or Multifamily dwellin;s: Apply for demolition penuit for�
x��3'
" - ,�"n
_
existing buildinsrW. Demolition pennit is required prior to issuance of buildlr,gIN,
0\ R`THFrOOLATER r s}Y
� s t
a L;CLDCNGPLkA RF11£\1
�rlrt��
permit for new building.
P r
1" xhY�il --& C 'Y•
Iflc> apR1 s"j<',s ' �i�
i F,c'rl e- F Y- �"' a g y y1.
�pLALYGPL44rP.\1ElY�t
�
Commercial Bldgs: Provide a completed Hazardous Materials Disclosu7
"e� �yddW11�C� \'k � �i�6 { "�rfi4.�•�
} t
D? ST4�DARD F
� ,R{� gimry--��y�y� � �L YQSi?Tcy1 +� � �r
❑ PLBLIC £
form if any Hazardous Materials are being used as part of this project.
� tr
1�`OR�S�
'YFIRL`
DEPT
_ Co ofPlanning Approval Letter or Meeting with Planning prior to
Copy pp J o
RDI�TRJC'k:
submittal of Building Pennit application.
aL]t-42ifOR�' irrs�
T ,, tte_s x
iL�uS�.'�IT}Y.SE\}
a t " n s .,
BldgApp_2011.doc rev sed 06121111
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO: B-2017-0366
20097 JOHN DR CUPERTINO, CA 95014-4414 (369 33 035) OWNER/BUILDER
OWNER'S NAME: THORNE DARLENE G TRUSTEE
OWNER'S PHONE: 408.724-0409
LICENSED CONTRACTOR'S DECLARATION
License Class Lic. #
Contractor OWNER/BUILDER Date
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.
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.
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 04/28/2017
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of the
Or= reasons:
I, as owner of th& property=or=my crnploy6es-with'wages`as_their-sole
compensation, will U& 6i work, -and the -structure -is not intended:or 9ffered for
sale -(Sec -7044; Business-& Professions Code)
I, as,)owner of the property, am exclusively contracting with licensed
�✓ contractors to construct the project (Sec.7044, Business & Professions Code).
I hereby affirm under penalty of perjury one of the following three declarations:
r. 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.
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 tlie. Wo'rker's'Compensationrovisions 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.
DATE ISSUED: 04/28/2017
PHONE -NO:
BUILDING PERMIT INFO:
X BLDG X ELECT _PLUMB
_ MECH X RESIDENTIAL _ COMMERCIAL
JOB DESCRIPTION:
REMODEL KITCHEN (211 S.F.); REMODEL DOWNSTAIRS
BATHROOM AND CREATE 1/2 BATH UNDER STAIRS (71 S.F.);
REMODEL FAMILY RM & CREATE (N) BEDROOM (260 S.F.);
REMODEL LIVING RM (284 S.F.); RELOCATE LAUNDRY TO
GARAGE; RELOCATE & UPGRADE MAIN PANEL (200 AMP); ADD
(1) SUB PANEL (100 AMP); REMODEL UPSTAIRS BATHROOMS
AND CLOSET (220 S.F.).
Sq. Ft Floor Area: I Valuation: $85000.00
APN Number: Occupancy Type:
369 33 035
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: 04/28/2017
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: 04/28/2017
ALL ROOF COVERINGS TO BE CLASS "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 9.12 and
the Health & Safety Code, Sections 25505, 25533, and 25534.
Owner or authorized agent:/ 4�4.�,�
Date: 04/28/2017
CONSTRUCTION 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
Professional
add -
O&tM/-
PMR)
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT - BUILDING DIVISION
10300 TORRE AVENUE - CUPERTINO, CA $50.143255
(408) 777-3228 - FAX (408) 777-3333 - buildhorm.cuDertino.ort3
❑ I3E«r conrsTxvCnoW
❑ . DITION - REVISION /DEFERRED ORIGIN?t.L PERh4IT
MW
PROJECT ADDRESS zoog7 c�D . r • I APN 4 �jb -- ✓ -' D3,-
jj jj
I l
Ct.+j�'4D%j �� n pH023E C �T E-h�,4iL
Oi�vTEPNkMEcom
STREETADDPESS � CITY, STATE, ZIP ��� +D F�
°° 5 r I
CO?dT.SC7 NAME SUSS o Chep "ONE 4,0�- ty,��r D} E A�CJ'V� �/ltt�+WII Wal}C�•
STREET ADDRESS 20 ToJI. .{ t CITY, STATE, ZIP
FA
.X
OWER ❑ OVn,"R•BULDER ❑ OVIh�JRAGENT ❑ COh7RACTOR ❑ C01.'TRACTOR AGENT 'A ARCHITECT ❑ ENGINTER ❑ DE\ eLOP%R '❑ TEhA�T
CON-DLACTORNAME.,..`-- , f�• LICENISEXUldiBER LiCENSETWE,
BUS. LICK
COMPAh1 NAME
E-MAIL
FAX
STREET ADDRESS
CITY, STATE, ZtP
PHONE
BUS. LIC;
AIZCHTTECTirNOINEERMA-ME 1,rson f+)�A„�
j. Chen
LiCENSENUMBF11
COMPAh'YMWE E•h4fiII.
_ I5iQl 9UWC eA9 @.. q 00 . CM F.4X
5"1'REEP PDDP ESS CITY. STATE, ZIP PHONE
Lo -fir 4 # I?R .,.. �f �, j - - V,s7?
�'c�br�l�- �°c�Y ���c,�'i��"nno(1zt :�s�� Ccrv�-^��--��a�hr► �n�a�eQ
!4- ba4VMM
-WOU A
- K
remove rYt P�D fi
i i
'ISTm E PROPOSED t'SE STR TYPE 'STORIES
j
j -
R Ism �V � 71 USE
Pfi
OCC. I
SQ.F•r.
{ VALUATION (S)
I
A �o o AL L=R�LITA�k 733 ;-T t.Z07 0
-
BATSP.00M KITCHEN ` OTHER -
XMAGDELAREA { i Ri 40DELARE.4 j' E REMODELAP.EA :
PORgiAREA AREATOTAL DEC,''P•%ORCfI. " GARAGEAREA: J3 AL ti
'ATTACH
5 +78
I)WELLLNGUNITS: ISASECONDi:'_QT YES S&CO?ib STORY []-IES
&EL G ADDED? PO AnDITION? X31 k0
PRE -APPLICATION - EI T'£S LF I-T.S, PROVJDECOPY OFT'' I IS THE DLDO An ❑ 'ES ""= TOTAL \' ALLiATION'
PL.A.X1,,H43APPL-. ❑N0 PLA1,.1,WG.APPROVAII-n7ER J EICHLERHOAIE?
By toy signature below. I certit, to each of the folimuing; I am the propert}' owner or authorized agent t on the property oNvner's �ebalf. 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 Iaws relating to buil ing comet struction• I authorize representatives of Cupertino to enter the above -identified property for ' spe tion purposes.
'Cb
SimatureofApplicant/Agent: Date; 3rC?=�1) j
t4I:I�I'TALII�J=O REQUIRED ,,.��`=kas�• �=::_ °•�:=:::^�i=: _ ,+�.� ,:,4:;:.��s.
SUPPLEMENTAL INFORMATION
::�::�::-=.PL4.ICHECKTYPEi?;�•�.c ��:=�:;;t�y.;A:c�:120U_TZNGSI..IP���"- �=.:-s_•
i
1\ett SFU or ]�4ultifasnil�) dji+ellings: Apply for demolition permit for.-r.,_.__�_-�:=^��_
HLrrLIi.L0iG ff P.I
.TIi£'GOLM1TER? :
`N
e� Istinabuildings. Demolition ennitisrequired prior toissuanceofbuildir,a :^;v;;'.. a::=-- _•-'>>- __ _.: ham;_ -.Y-,;=,:.:::':,;
�'.�•'-`- _ u''.'v - _ 'sr k;":=� mar _:•-"?:y°: _�' _
�xT1lit for new building. _= - -- - - - __--
--
_ Commercial Bldgs: Provide a completed Hazardous Materials 7isrlosue _- '-+� "�•� '`���}: , T
t .atm
R ti [ r =%_s'-__.�.::•:.v
;orn'ifa1T HazardouSl�+Fterizls are iiia used - -- -= -- - - -_ - -_-- -
kt.. t s as art of thin • ro'ect.-
ia .l iI. •'ICS - -
--
_
eetin a7thPla II� prior to of Plannin g Approval Le_•�:�� vac r- _
'_- ter or A
`4],V _.j S.-•'-�vic.>�e? w---.^�:=.. r i':�:iy{•.:�-`�2.1'•n .a.
LIL2Y_.SE�i�DP= -i-?-
submittal ofBuilding Pe it aPplication.
_ a'•-r;:a�z�•T_:zv;;�� - o,''" u; ter'-•-�-:',-a�`::r� s --—:�^-_-';'r _
- _ -
».•r.:-�,'.gs"=_may _ _ _ _ _ _ - -:a.,..- _ _- — -- _ _ `- _ _ _
Bldgfpp_2011:doc revised 06121111
m?
CUPERTINO
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE - CUPERTINO, CA 95014-3255
(408) 777-3228 • FAX (408) 777-3333 • building a7cupertino.org
Dear Property Owner(s):
An application for a building permit has been submitted in your name listing yourself as the builder of the property
improvements specified at:
SITE ADDRESSAPN #
j(� h i1
OW
Z,NER--a SAME ; Gots. J Mo OWNER AD_QIRESi�P_HCom, A'71w_19 *
ll�
e are p oviding you with an O ner-Builder Acknowledgment and Informatio Verification Form to make u aware of
your responsibilities and possible risk you may incur by having this permit issued in your name as the Owner -Builder. We
will not issue a building permit until you have read, initialed your understanding of each provision, signed, and
returned this form to us at our official address indicated. An agent of the owner cannot execute this notice unless
you, the property owner, obtain the prior approval of the permitting authority.
OWNER'S ACKNOWLEDGMENT AND VERIFICATION OF INFORMATION
(DIRECTIONS: Please read and initial each statement below to signify you understand or verify this information.)
�1. 1 understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner -
Builder" building permit that erroneously implies that the property owner is providing his or her own labor and material
personally. I, as an Owner -Builder, may be held liable and subject to serious financial risk for any injuries sustained by
an unlicensed person and his or her employees while working on my property. My homeowner's insurance may not
provide coverage for those injuries. I am willfully acting as an Owner -Builder and am aware of the limits of my
f
insurance coverage for injuries to workers on my property.
,.. c 2. 1 understand building permits are not required to be signed by property owners unless they are responsible for
the construction and are not hiring a licensed Contractor to assume this responsibility.
�3. 1 understand as an "Owner -Builder" -i am the responsible party of record on the permit. I understand that I may
protect myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her
name instead of my own.
[� 4. 1 understand Contractors are required by law to be licensed and bonded in California and to list their license
numbers on permits and contracts.
�,-L),� 5. 1 understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the
total value of my construction is at least five hundred dollars ($500), including labor and materials, I may be
considered an "employer" under state and federal law.
L�6. I understand if I am considered an "employer" under state and federal law, I must register with the state and
federal government, withhold payroll taxes, provide workers' compensation disability insurance, and contribute to
unemployment compensation for each "employee." I also understand my failure to abide by these laws may subject
me to serious financial risk.
�7. 1 understand under California Contractors' State License Law, an Owner -Builder who builds single-family
ential structures cannot legally build them with the intent to offer them for sale, unless all work is performed by
licensed subcontractors and the number of structures does not exceed four within any calendar year, or all of the work
is performed under contract with a licensed general building Contractor.
%�,,
"__K8. I understand as an Owner -Builder if I sell the property for which this permit is issued, I may be held liable for
any financial or personal injuries sustained by any subsequent owner(s) that result from any latent construction
defects in the workmanship or materials.
OwneYBuilderForm 2010. doe revised 04/14/10
�a
9. 1 understand I may obtain more information regarding my obligations as an "employer" from the Internal
Revenue Service, the United States Small Business Administration, the California Department of Benefit Payments,
and the.California Division of Industrial Accidents. I also understand I may contact the California Contractors' State
License Board (CSLB) at 1-800-321-CSLB (2752) or www.cslb.ca.gov for more information about licensed
contractors.
(10. 1 am aware of and consent to an Owner -Builder building permit applied for in my name, and understand that I
am the party legally and financially responsible for proposed construction activity at the site address listed above.
11. I agree that, as the party legally and financially responsible for this proposed construction activity, I will abide
by all applicable laws and requirements that govern Owner -Builders as well as employers.
12. 1 agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the
m rmation I have provided on this form. Licensed contractors are regulated by laws designed to protect the public. If
you contract with someone who does not have a license, the Contractors' State License Board may be unable to
assist you with any financial loss you may sustain as a result of a complaint. Your only remedy against unlicensed
Contractors may be in civil court. It is also important for you to understand that if an unlicensed Contractor or
employee of that individual or firm is injured while working on your property, you may be held liable for damages. If
you obtain a permit as Owner -Builder and wish to hire Contractors, you will be responsible for verifying whether or not
those Contractors are properly licensed and the status of their workers' compensation insurance coverage.
CONSTRUCTION LENDING AGENCY
(DIRECTIONS: Please complete the following construction lending agency information.)
I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued
(Sec 3097 Civ.)
Lender Name:
Lender Address:
Before a building permit can be issued, this form must be completed and signed by the property owner and
returned to the agency responsible for issuing the permit. Note: A copy of the property owner's driver's license,
form notarization, or other verification acceptable to the city may be required to be presented when the permit is issued
to verify the property owner's si nat e.
Property'Owner's Signature: Date: — !`/
---------------------------------------------------------------------------------------------------------------------------------------------
(NOTE: The following Authorization Form is required to be completed by the property owner only when designating an
agent of the property owner to apply for a construction permit for the Owner -Builder).
AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF
Excluding the Notice to Property Owner, the execution of which I understand is my personal responsibility, I hereby
authorize the following person(s) to act as my agent(s) to apply for, sign, and file the documents necessary to obtain an
Owner -Builder Permit for my project.
Scope of Construction Project (or Description of Work):
Project Location or Address:
Name of Authorized Agent:
Address of Authorized Agent:
Tel No
I declare under penalty of perjury that I am the property owner for the address listed above and I personally filled out the
above information and certify its accuracy. Note: A copy of the property owner's driver's license, form notarization, or other
verification acceptable to the, city may be required to be presented when the permit is issued to verify the property owner's
signature.
Property Owner's Signature:
Date:
OwnerBuilderFonn 2010.doc revised 04/14/10
/ Building Department
City Of Cupertino
10300 Torre Avenue
�Sc.�ss Cupertino, CA 95014-3255
Telephone 408-777-3228
CUPERTINO
Fax: 408-777-3333
CONTRACTOR/SUBCONTRACTOR LIST
JOB ADDRESS 2ob�? �3�h vi i2 PERMIT# R - 20(7-0 3 6c
OWNER'S NAME /VGi,qii/ PHONE# 108 o tico e
GENERAL CONTRACTOR.�hPl l61 ma),,.; BUSINESS LICENSE# at,t $6-
ADDRESS 3 7.,2.7 <e rtt keAt 5 0,4,, ®� , c 4 CITY/ZIPCODE d g
*Our municipal code requires all businesses working in the city to have a City of Cupertino business license.
NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE
GENERAL CONTRACTOR AND ALL SUBCONTRACTORS HAVE OBTAINED A CITY OF CUPE_RTINO_
BUSINESS LICENSE.
I am not using any subcontractors. f' /z /L-°t
Signature Date
Please check applicable subcontractors and complete the following information.
V SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets &Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring/Carpeting
Linoleum/Wood
Glass/Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Painting/Wallpaper
Paving
Plastering Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
(7[
Owner/Contractor Signature SII"
g ate f