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B-2017-0870CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: CONTRACTOR: PERMIT NO: B-2017-0870 10850 E ESTATES DR CUPERTINO, CA 95014-4534 (369 22 005) OWNER BUILDER OWNER'S NAME: HOFLAND LYNN M AND ROSANNE I DATE ISSUED: 06/01/2017 OWNER'S PHONE: 408-507-1914 PHONE NO: LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: License Class Lic. # Contractor OWNER BUILDER Date 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: INSTALL CONCRETE SLAB (12X16 SF); I hereby affirm under penalty of perjury one of the following two declarations: --REVISION #1: INSTALL 192 S.F. TUFF SHED ON CONCRETE SLAB 1. I have and will maintain a certificate of consent to self -insure for Worker's ISSUED 06/28/2017 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 Sq. Ft Floor Area: Valuation: $4000.00 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 369 22 005 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 regulations per the Cupertino Municipal Code, Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION. Signature Date 6/28/2017 Issued by: Kim Dunbar Date: 06/01/2017 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) 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: 6/28/2017 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 z. 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 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 Co e, 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: APPLICANT CERTIFICATION Date: 6/28/2017 1 001 I certify that I have read this application and state that the above information is CONSTRUCTION LENDING GENCY 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. W Licensed Signatur ate 6/28/2017 Professional U, CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 REV1S 2 (408) 777-3228 • FAX (408) 777-3333 - building(a cuoertino.org ❑ NEVA' CONSTRUCTION ❑ ADDITION ❑ ALTERATION / TI REVISION /DEFERRED ORIGINAL PERMIT # L 0 —0 p l� PROTECT ADDRESS d —6 o S r APN # Z2-- Coy — ( v y OWNER NAME / PHONE O gY&��� EMAIL��I yy�� (D/`Divi �j'��G� STREET ADDRESS � CITY, sr� 1 � FAX � r c / CONTACT NAME C PHONE E-MAIL C� STREET ADDRESS CITY, STATE, ZIP FAX KOWNTER ❑ OWNER -BUILDER ❑ OWNERAGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT 1 CONTRACTOR NAME �r . ^cin /S ., I _I /1 LICENSE NUMBER LICENSE TYPE 11.J� UCiY L l X BUS. LIC # COMPANY NAME E-MAII FAX STREET ADDRESS I CITY, STATE, ZIP PHONE ARCHITECT/ENGINTEER NAME LICENSE NUMBER BUS. LIC # COMPANY NAME E -MATT, FAX STREET ADDRESS CITY, STATE, ZIP PHONE DESCRIPTION OF WORK EXISTING USE PROPOSED USE CONSTR. TYPE # STORIES I USE TYPE OCC. SQ.FT. VALUATION (S) FAZSTG NEW FLOOR DEMO TOTAL AREA AREA AREA NET AREA BATHROOM KITCHEN OTHER REMODEL AREA REMODEL AREA REMODEL AREA PORCH AREA DECK AREA TOTAL DECK/PORCH AREA GARAGE AREA: LJ DETACH ❑ A7rACH # DWELLING UNITS. IS A SECOND UNIT ❑ YES SECOND STORY ❑ YES - BEING ADDED? E] NO ADDITION? ❑NO PRE -APPLICATION []YES IF YES, PROVIDE COPY OF IS THE BLDG AN ❑ 1'ES;RECEIVED BY TOTAL }.LU.4T10N: PLANWLNG APPL # [:]NO PLANNING APPROVAL LETTER EICHLER BO.'dP.? ❑ NO }j Q By my signature below, I certify to each of the following: I am the property owner or authorized agent to act on 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 a *ori rep ntativ of Cupertino to enter the above -i ntifiedpr erty for inspection purposes. Signature of Applicant/Agent: Date: 6z SUPPLEMENTAL rKFORMATION tTQUfLD PLAN,CHECK=E . , ' ❑ ovER-TaE coui.rER ❑BuriDlt�cpL New SFD or Multifamily dwellings: Apply for demolition permit for existing building(s). Demolition permit is required prior to issuance of building " �>zE«w permit for new building. El EXPRESS ❑ - PLAI\AInGPLAN RE«W _ Commercial Bldgs: Provide a completed Hazardous Materials Disclosure ❑° STaf.iiAnD ❑ euBLICROIiIs form if any Hazardous Materials are being used as part of this project. ❑ L AItGE ❑ FIREDEPT . Copy of Planning Approval Letter or Meeting with Planning prior to ❑ MAJOR ❑ submittal of Building Permit application. SANITARI SE�SERDISTRICT, ' . ❑"; M'MONNiENTAL H1ALTii BgdgApp_2011.doe revised 06/21/11 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: CONTRACTOR: PERMIT NO: B-2017-0870 10850 E ESTATES DR CUPERTINO, CA 9501411534 (369 22 005) OWNER/BUILDER OWNER'S NAME: HOFLAND LYNN M AND ROSANNE I DATE ISSUED: 06/01/2017 OWNER'S PHONE: 408-507-1914 PHONE NO: LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: License Class Lic. # Contractor OWNER/BUILDER Date 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: INSTALL CONCRETE SLAB (12X16 SF) 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 Sq. Ft Floor Area: Valuation: $4000.00 permit is issued. APPLICANT CERTIFICATION I certify that 1 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 369 22 005 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 regulations per the Cupertino Municipal Code, Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION. Signature Date 06-01-20107 Issued by: Kim Dunbar OWNER-BUILDER DECLARATION Date: 06/01/2017 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 Wcontractors to construct the project (Sec.7044, Business & Professions Code). Signature of Applicant: Date: 06-01-20107 I hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER 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. HAZARDOUS MATERIALS DISCLOSURE z. 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. 1 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: APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is Date: 06-01-20107 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. Signature Date 06-01-20107 ;� Licensed Professional CUPERTINO A NEW CONSTRUCTION CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 r FAX (408) 777-3333 r building(cDcupertino.org v`^' l-4 00 -D ❑ ADDITION ❑ ALTERATION / TI ❑ REVISION /DEFERRED ORIGINAL PERMIT 11 � :I PROJECT ADDRESS %'��r Cr APN # r Z fl C Cl s � lJJ OWNER NAME PHONE1 �%S-5o7- E-MAIL 5�, ciretz9gol.com , hi? O 4 i1 / oie STREET ADDRESS i0 gS—O CITY, STATE, ZIP rD �j FAX CONTACT NAME J PHONE E-MAIL STREET ADDRESS CITY, STATE, ZIP FAX 14 OWNER 9OWNER-BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME LICENSE NUMBER LICENSE TYPE BUS. LIC # COMPANY NAME E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS. LIC # COMPANY NAME E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE DESCRIPTION OF WORK I e _ Se2�f6cIC Gn d �t sdaek socrtl,5�'d�r Dn EXISTING USE PROPOSED USE CONSTR. TYPE #STORIES USE TYPE OCC. SQ.FT. VALUATION ($) EXISTG NEW FLOOR DEMO TOTAL AREA AREA AREA NET AREA BATHROOM KITCHEN OTHER REMODEL AREA REMODEL AREA REMODEL AREA PORCH AREA DECK AREA TOTAL DECK/PORCH AREA GARAGE AREA. DETACH ❑ ATTACH # DWELLING UMTS: IS A SECOND UNIT ❑ YES SECOND STORY []YES BEING ADDED? []NO ADDITION? []NO Q 00 T r i A "n" PLANNING APPL # ❑ ❑ NO PLANNING APPROVAL LETTER EICHLER HOMEY NOME PRE -APPLICATION ❑YES IF YES, PROVIDE COPY OF IS THE BLDG AN ❑YESWall/ / By my signature below, I certify to each of the following: I am the property owner or authorized agent to act on the property owner's behalf. I h e 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 repr sentatives of Cupertino to enter the above -identified property for inspection purposes. Signature ofApplicant/A Dat ' V{u- OL G C9 SUPPLEMENTAL FORMATION R-EQUfRFD New SFD or Multifamily dwellings: Apply for demolition permit for existing building(s). Demolition permit is required prior to issuance of building permit for new building. Commercial Bldgs: Provide a completed Hazardous Materials als Disclosure form if any Hazardous Materials are being used as part of this project. � Co of Planning Approval Letter or Meeting with Planning prior to PY g PP g g P i�/ „✓,;,'/ice%�j.��� � � /'% �%� submittal of BuildingPermit application. pP B1dgApp 201 Woe revised 06/21/11