B-2017-1402CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: -
CONTRACTOR:
PERMIT NO: B-2017-1402
21134 HAZELBROOK DR CUPERTINO, CA 95014-1663 (326 55 028)
HOME DEPOT U S A
INC
ATLANTA, GA30339
OWNER'S NAME: SU HUNG I TRUSTEE
DATE ISSUED: 08/22/2017
OWNER'S PHONE: 408-603-7885
PHONE NO: (770) 433-8211
LICENSED CONTRACTOR'S DECLARATION
BUILDING PERMIT INFO:
License Class C17, B Lic. #62331
Contractor HOME DEPOT U S A INC Date 09/30/2018
3C 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:
REPLACE WINDOW (7) - LIKE FOR LIKE TO MEET EGRESS
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 wbich'this permit is issued.
I have and will maintain Workers 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: $5488.00
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 55 028
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 ISNOT 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.
l nature ate 8/22/2017
Issued by: Jasmine Archbold
Date: 08/22/2017
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 roofmg material being installed. If a roof is
i.!' 'I, as owner of the property or my employees with wages as their sole
installed without first obtaining an inspection, ] agree to remove all new materials for
compensation„ will do tha work, and the structure is not intended or offered for
inspection.
-sale (Sec.7044',Business & Professions Code)
z.; iI as owner of theproperty am exclusively contracting with licensed
Signature of Applicant:
contractors to construct the project (Sec.7044, Business & Professions Code).
Date: 8/22/2017
I hereby affirm under penalty of perjury one of the following three declarations:
i.1 II'bave 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 anyperson 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, Ibecome 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.
O - er or authorized agent:
AAPPLICANT
CERTIFICATION 71
e: rl/2W2017
I certify that I have read this appl)dation and state that the above information isO
O END CY
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 ekpenses;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,ali 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 8/22/201.7
Licensed
professional
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE e CUPERTINO, CA 95014-3255
(408) 777-3228 • building@cupertino.org PEIVIIT #B - `0 1
CUPERT'INO
NEW CONSTRUCTION ❑ ADDMON ALTERATION ❑ T.I. ❑ MEP ❑ RE -ROOF [:] SWMM41NG POOL/SPA
B
� yoz
PROJECT ADDRESS
t
APN # -5
OWNERNAME PHONE
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fog
E-MAIL)
STREET ADDRESS
2 I 1-5,f 44 pcoi_-
CITY, STATE, ZIP
c ,q ' Sd44
CONTRACTOR NAME ❑ OWNER -BUILDER
COMPANY NAME
LICENSE NUMBER
LICENSE TYPE
_
STREET ADDRESS
CITY, STATE, ZIP
E-MAIL
PHONE
BUS. LIC #
❑ ARCHITECT ❑ OWNER ❑ OwNERAGENT ACONTRACTORAGENT❑ ENGINEER ❑ DEVELOPER ❑ TENANT
CONTACT NAME
E-MAIL
STREET ADDRESS
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CITY, STATE, ZIP PHONE
r�J�1,�-,� `l'S�FS
5149. z 2 G G
DECRIPTON I 1 I r( NDO e5 (JD % �t� A -N r
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SINGLE-FAMILY/DUPLEX ❑ MULTI -FAMILY ❑ INDUSTRIAL ❑ COMMERCIAL
USE
TYPE
OCC
SQ.FT.
VALUATION ($)
EXISTING USE
I EXISTING SF
NEW FLOOR SF I
PORCH
SF DECK SF
DEMO SF
STORIES #
TOTAL NET SF
REMODEL
REMODEL KITCHEN I
REMODEL OTHR GARAGE
❑ ATTACHED
BATHROOM SF
SF
SF SF
❑ DETACHED
EXISING ❑ YES
EICHLER ❑ YES.
SECOND STORY ADDITION ❑ YES
FIRE SPRINKLERS ❑ NO
❑ NO
❑ NO
DWELLING SECOND DWELLING ❑ YES []ATTACHED[] DETACHED OTHER
UNITS # UNIT ADDITON: ❑ NO S F
I
POOLS ❑ FIBERGLASS ❑ VINYL -LINED ❑ GUNITE ❑ PREFABRICATED
POOL - SF SPA - SF SPA ATTACHED ❑ YES ❑ NO TOTAL - SF
Commercial or Multi -Family Buildings with Public'Swimmigg Pools requires Department of Environmental Heath approaal
RECE Y:
TOTAL VALUATION•
5
RE -ROOF
EXISTING ROOF TYPE: ❑ BUILT-UP ROOF ❑ ASPHALT SHINGLES ❑ WOOD SHAKES ❑
WOODS GLES ❑ TILE OTHER (SPECIFY)
REMOVE /REPLACE ❑ NO
IF NO
PLYWOOD [:]%" ❑,3/8„
PLYWOOD TYPE:
PITCH:
ROOF CLASS
❑ YES
I # OF LAYERS
THICKNESS ❑ 5/8" OTHER I
❑ OSB ❑ CDX OTHER
:12
I A
PROPOSED ROOF TYPE: []BUILT-UP ROOF 11ASPHALT SHINGLES ❑ WOOD SHAKES ❑WOOD SHINGLES ❑ OTHER
*Provide a signed copy of the Cupertino's Tear -Off Policy SF #of SQUARES
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 authorize representatives of Cupertino to
enter the above -identified property for inspection purposes. I acknowledge and authoriz -information contained on this application form
to be made available for publicreeord. 22!
Signature
of Applicant/Agent; Date:
SUPPLEMENTAL iNFO REQUIRED
*New SFD/Second Dwelling Units/Multifamily Dwellings: Demolition permit is required prior to issuance of a building permit for all new construction.
*Commercial Buildings: Provide a completed Hazardous Materials Disclosure form if any Hazardous Materials are being used as part of this project.
*Copy of Planning Approval Letter or, Meeting with Planning prior to submittal of Building Permit application.
*HOA -Provide a letter of approval from the Home Owner's Association
BldgApp 2017.doc revised 08101117