B-2017-0710to
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS:
CONTRACTOR:
PERMIT NO: B-2017-0710
22330 HOMESTEAD RD APT 223 CUPERTINO, CA 95014-0137 (326 59 048)
UNIVERSAL
DEVELOPING INC
SAN CARLOS, CA
94070
OWNER'S NAME: VAN ORDEN PAMELA JOAN TRUSTEE
DATE ISSUED: 05/04/2017
OWNER'S PHONE: 408-921-9101
PHONE NO: (650) 591-7667
LICENSED CONTRACTOR'S DECLARATION
BUILDING PERMIT INFO:
License Class B Lic. #622858
Contractor UNIVERSAL DEVELOPING INC Date 07/31/2017
X X BLDG _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:
KITCHEN REMODEL (44 S.F.); BATHROOM REMODEL (87 S.F.)
I hereby affirm under penalty of perjury one of the following two declarations:
REV #1 - REVISE FRAMING PLANS - ISSUED 8/4/2017
1. I have and will maintain a certificate of consent to self -insure for Worker's
Compensation, asprovided for by Section 3700 of the Labor Code, for the
performance of the work for which this permit is issued.
have and will maintain Worker's Compensatign Insurance, as provided for by
ection 3700 of the Labor Code, for the performance of the work for which this
Sq. Ft Floor Area:
Valuation: $90000.00
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
APN Number:
Occupancy Type:
and state laws relating to building construction, and hereby authorize
326 59 048
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.
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
Additionally, the applicant understands and will comply with all non -point
source regulati6ns per the Cupertino Municipal Code, Section 9.18.
180 DAYS FROM LAST CALLED INSPECTION.
ature �"" Date 814/2017
Issued by: Abby Ayende j
Date:05/04/2017 '
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
m. I, as owner of theproperty,or m em to employees with wages as their sole
Y P Y g
installed without first obtaining an inspection, I agree to remove all"new materials for
i�
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 ofApplicant:
contractors to construct the project (Sec.7044, Business & Professions Code).
Date: 8/4/2017
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
a. 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.er
or authorized agent:
APPLICANT CERTIFICATION
Date: 8/4/2017,
1 certify that l have read this application and state that the above information is
CONSTRUCTION LENDING AGENCY
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.
Licensed
Signature Date 8/4/2017
Professional
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISIOI�
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228 • FAX (408) 777-3333 • buildingC_cupertino.org
CUPERTINO I
❑ NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION / TI VISIO / DEFERRED
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ORIGINAL PERMIT #
PROJECT ADDRESS21,6,%\ ®Em �
APN # 2f,04-8
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FAX
CONTACT NAME
PHONE
E-MAIL
STREET ADDRESS
CITY, STATE, ZIP
FAX
❑ OWNER ❑ OwNER-BUILDER ❑ OwNERAGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAM
LICENSE NUMBER(,Z2dc
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ARCHITECT/ENGINEERNAME
LICENSENUMBER
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COMPANY NAME
E-MAIL
FAX
STREET ADDRESS
CITY, STATE, ZIP
PHONE
DESCRIPTION OF WORK rl— ^ '
2K1 �1 �iiSiv�
EXISTING USE
PROPOSED USE - CONSTR
TYPE
# STORIES
USE
TYPE
OCC.
SQ.FT.
VALUATION ($)
EXISTG
NEW FLOOR
DEMO
TOTAL
AREA
AREA
AREA
NETAREA
BATHROOM KITCHEN
OTHER
REMODEL AREA REMODEL AREA
REMODEL AREA
,
PORCH AREA
DECKAREA
TOTAL'DECKTORCH AREA
GARAGE AREA: D DETACH
❑ ATTACH
# DWELLING UNITS:
ISA SECOND UNIT ❑ YES
SECOND STORY ❑ YES
BEING ADDED? ❑NO
ADDITION? ANO
PRE -APPLICATION ❑ YES IF YES, PROVIDE COPY OF
IS THE BLDG AN ❑YESRE
- IVED BY s
TOTAL VALUATION:
PLANNING APPL # ❑ NO PLANNING APPROVAL LETTER
EICHLER HOME? ❑ NO
By my signature below, I certify to each of the following: I am the property owner or authorized agent t act on tie property owner's behal . 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 buildinggonstruction. I authorize representatives of Cupertino to enter the above- denti d property for inspection purposes.
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Signature of Applicant/Agent:Date:
Agent: 11`
SUPPLEMENTAL INFORMATION REQUIRED
Q
y PL'AN.CHECI{T.YPE
?ROUTINGSLIP _.,,.,,�' �„�,�;
New SFD or Multifamily dwellings: Apply for demolition permit for
❑
_
existing building(s). Demolition permit is required prior to issuance of building
O\ ER THE COUNTER
F
BUH DING PLAN REVIEW
"
permit for new building.
EXPREss z `
❑ $LANNINGPLAN REVIEW ''
Bldgs: Provide a completed Hazardous Materials Disclosure
❑, sTANDARDn
❑ PuBLIc woRxs ,
_Commercial
form if any Hazardous Materials are being used as part of this project.
❑TARGE
� � � � ria
❑� FIRE DEPT � 1s t � t
Copy of Planning Approval Letter or Meeting with Planning prior to
a
{
_
submittal of Building Permit application.
MAJOR "
❑ SANITARY SEWER DISTRICT
�, r;:
,ENVIROIVMENTALHEALTHt
BldgApp_2011.doc revised 06121/11
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO: B-2017-0710
22330 HOMESTEAD RD APT 223 CUPERTINO, CA 95014-0137 (326 59 048) UNIVERSAL
DEVELOPING INC
SAN CARLOS, CA
94070
OWNER'S NAME: VAN ORDEN PAMELA JOAN TRUSTEE
ISSUED: 05/04/2017
OWNER'S PHONE: 408-921-9101 1 1 PHONE NO: (650) 591-7667
License Class 5_-1 Lic. #622858
Contractor UNIVERSAL DEVELOPING INC Date 07/31/2017
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.
(� z. 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 re lations per the Cupert' nicipal Code, Section 9.18.
Signature Date 5/4/2017
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of the
following two reasons:
t. 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)
2. 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:
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.
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 5/4/2017
BUILDING PERMIT INFO:
X BLDG —ELECT —PLUMB
_ MECH X RESIDENTIAL _ COMMERCIAL
JOB DESCRIPTION:
KITCHEN REMODEL (44 S.F.); BATHROOM REMODEL (87 S.F.)
Sq. Ft Floor Area: I Valuation: $90000.00
APN Number: Occupancy Type:
32659 048
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
Issued by: Abby Avende
Date: 05/04/2017
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: 5/4/2017
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 & Safetye, Sections 2550 nd 25534.
Owner or authorized agent:
Date: 5/4/2017
CONSTRUCTION LE D GAG y
I hereby affirm that there is a construction lends 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
CUPERTINO
13-20t�- - oqrio
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228 • FAX (408) 777-3333 • building(d)cupertino.org
❑ NEW CONSTRUCTION ❑ ADDITION ZALTERATION / TI ❑ REVISION /DEFERRED ORIGINAL PERMIT #
PROJECT ADDRESS O FtV
APN # 37 O�,y�
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{'OWNER ❑ OWNER -BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT
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CITY, STATE, ZIP
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PHONE
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DESCRIPTION OF WORK
�.
ream
EXISTING USE
PROPOSED USE CONSTR
TYPE
I # STORIES
USE
TYPE
OCC.
SQ.FT.
VALUATION ($)
EXISTG
AREA
NEW FLOOR
AREA
DEMO
AREA
TOTAL
NET AREA
�Q `..
(M
BATHROOM
REMODEL AREA
KITCHEN
REMODEL AREA
OTHER
REMODEL AREA
PORCH AREA
DECK AREA
TOTAL DECK/PORCH ARE
I GARAGE AREA: LIDETACH
❑ ATTACH
# DWELLING UNITS:
IS A SECOND UNIT ❑ YES
SECOND STORY ❑ YES
BEING ADDED? ONO
ADDITION? [-]NO
PRE -APPLICATION ❑ YES IF YES, PROVIDE COPY OF
IS THE BLDG AN ❑ YES
RECEIVED BY:
ALUATION:
PLANNING APPL # ❑ NO PLANNING APPROVAL LETTER
EICHLER HOME? ❑ NO
�Vo
By my signature below, I certify to each of the following: I am the property owner or authorized agent1to act on Ihe property owner's behalf. I have read this
application and the information I ve provided is corre t. I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relaf building cons Icti n. I authorize representatives of Cupertino to enter the above -identified property for inspection purposes.
Signature of Applicant/ Date:
SUPPL ENTAL O TION REQ RED
PLAN CHECK TYPE
ROIITING SLIP
❑ OVER-THE-COUNTER
❑ BUILDING PLAN REVIEW
_ New SFD or Multifamily wellin pply for demolition permit for
existing building(s). Demolition permit equired prior to issuance of building
permit for new building.
❑ EXPRESS
❑ PLANNING PLAN REVIEW
Commercial Bldgs: Provide a completed Hazardous Materials Disclosure
❑ STANDARD
❑ PUBLIC WORKS
form 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
❑ MAJOR
❑ SANITARY SEwER`OISTRICT
submittal of Building Permit application.
❑ EN IHONMENTAL HEALTH
B1dgApp_2011.doc revised 06/21111
2