B-2017-0903CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO: B-2017-0903
19161 ANNE LN CUPERTINO, CA 95014-3537 (375 07 011) COMPLETE
CONSTRUCTION
EXPERTS INC
SAN JOSE, CA 95129
OWNER'S NAME: RANCHES FEDERICO D AND CARMEN M
OWNER'S PHONE: 408-489-3691
License Class @ Lic. #1009320
Contractor COMPLETE CONSTRUCTION EXPERTS INC Date 12/31/2017
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:
t. 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 nt understands and will comply with all non -point
source regulatio s per the Qupertino Municipal Code, Section 9.18.
Signature Date 06-07-2017
DATE ISSUED: 06/07/2017
PHONE NO: (408) 650-2432
BUILDING PERMIT INFO:
X BLDG —ELECT —PLUMB
_ MECH X RESIDENTIAL _ COMMERCIAL
JOB DESCRIPTION:
2ND FLOOR BATHROOM REMODEL (40 SF)
Sq. Ft Floor Area: I Valuation: $3000.00
"N Number: Occupancy Type:
37507 011
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: 06/07/2017
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
t. 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
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 sball
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 06-07-2017
Signature of Applicant:
Date: 06-07-2017
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 C erh Municipal Code, Chapter 9.12 and
the Health & Safety Code Sectio -25505$
25533, and 25534.
C
Owner or authorized agent:
Date: 06-07-2017
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
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
CUPERTINO (408) 777-3228 •FAX (408) 777-3333 • building@cupertino.org 5-!01--I --- (M,3
❑ NEW CONSTRUCTION ❑ ADDITION ALTERATION / TI [I REVISION /DEFERRED ORIGINAL PEER (MI( T #_
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TOTAL
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# I)wELLING UNITS: 1S A SECOND UNIT ONES
SECOND STORY []YES
BEINC ADDED? ONO
ADDITION? ❑NO
PRE -APPLICATION ❑ YES IF YES, PROVIDE COPY OF
IS THE BLDG AN ❑ YES
XECH14 ATION_
PLANNING APPL # ❑ NO PLANNING APPROVAL LETTER
EICHLER HOME? ❑ NO
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By my signature below, I certify to each of the f ng: I am the property owner or authorized agent to act on the property owner's behalf. I have read this
application and the information 1 have provid is c ct. I *ave read the Description of Work and verify it is accurate. 1 agree to comply with all applicable local
ordinances and state laws relating to buildin co cti on(zeerrepresentatives of Cupertino to enter the above -identified property for inspection purposes.
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Signature of Applicant/Agent: ! ` Y Date:
SUPPLEMENTAL INFORMA EQUIRED
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_ 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.
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_ Commercial Bldgs: Provide a completed Hazardous Materials Disclosure
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form if any Hazardous Materials are being used as part of this project.
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_ Copy of Planning Approval Letter or Meeting with Planning prior to
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submittal of Building Permit application.
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B1dgApp_2011.doc revised 06/21/11