B-2017-1263 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2017-1263
19634 STEVENS CREEK BLVD CUPERTINO,CA 95014-2456(369 06 012) S M I CONSTRUCTION
INC
SAN LEANDRO,CA
94577-4321
OWNER'S NAME: EVERSHINE VI,LP DATE ISSUED:09/12/2017
OWNER'S PHONE:408-630-0030 PHONE NO:(510)351-3288
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class la Lic.#831166'
Contractor S M I CONSTRUCTION INC Date 01/31/2018 X BLDG _ELECT _PLUMB
MECH_RESIDENTIAL X 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:
CBI KITCHEN-T.I.;REMOVE PARTITION WALL,RELOCATE LIGHT
I hereby affirm under penalty of perjury one of the following two declarations: SWITCHES(2);REPAIR CEILING,REPLACE LIGHT FIXTURES(30
1. I have and will maintain a certificate of consent to self-insure for Worker's S.F.)
Compensation,as provided 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 Compensation Insurance,as provided for by
ection 3700 of the Labor Code,for the performance of the work for which this
permit is issued. Sq.Ft Floor Area: Valuation:$50000.00
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 06 012 A(Tenant Improvements)
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.
,- .
•
.
, -4400 e Date 9/12/2017 Issued by:Jasmine Archbold
Date:09/12/2017
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)
2. 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:9/12/2017
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
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 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 •„skbxn' r ,_
:9/12/2017 Date
APPLICANT CERTIFICATIONNCONS CON LENDING AGENCY
I certify that I have read this application and state that the above information is
correct.t 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 indeninify 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. I understand my plans shall be used as public records.
Licensed
Signature Date 9/12/2017 Professional
t-Z0q- 12-(0
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/, CONSTRUCTION PERMIT APPLICATION
� COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION��.,➢fs 10300 TORRE AVENUE•CUPERTINO,CA 95014-3255
CUPERTINO (408)777-3228•FAX(408)777-3333•buildinqcupertino.orq
❑NEW CONSTRUCTION ❑ ADDITION ❑^A�LTTE�RATION/TI ❑ REVISION/DEFERRED ORIGINAL PERMIT#
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OWNER NAME t \ n I�'-O PHONE i Deed E-MAIL
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CONTACT NAME Q��q PHONE E-MAIL
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❑OWNER ❑ OWNER-BUILDER El OWNER AGENT 0 CONTRACTOR ❑CONTRACTOR AGENT ARCHITECT El ENGINEER 0 DEVELOPER 0 TENANT
CONTRACTOR NAME i Fy LICENSE NUMBER LICENSE TYPE BUS.LIC# LIPD Lit 7
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STREET ADDRESS CITY,STATE ZIP PHONE
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ARCHITECT/ENGINEER NAME �n n LICENSE NUMBER / BUS.LIC
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DESCRIPTION OF WORK ' \
.�T T v-P COQ- ' 6 . � �C: �I,i,jc.lue?--
l i / /i t7/2 )29pPaCE regt, 'Cat h/ %
EXISTING USE PROPOSED USE ONSTR.TYPE #STORIES
USE TYPE OCC. SQ.FT. VALUATION($)
EXISTG NEW FLOOR DEMOTOTAL ,
AREA AREA I' AREA NET AREA
BATHROOM KITCHEN OTHER
REMODEL AREA ' REMODEL AREA REMODEL AREA
PORCH AREA DECK AREA i TOTAL DECK/PORCH AREA GARAGE AREA: ❑DETACH
i ❑ATTACH
1
#DWELLING UNITS: IS A SECOND UNIT ❑YES SECOND STORY El YES
BEING ADDED? ❑NO ADDITION? ❑NO
PRE-APPLICATION ❑YES IF YES,PROVIDE COPY OF IS THE BLDG AN ❑YES >REC V .:,,:,;1,.,..:':;`:,,,,,:; :r0:..,,,-,,,;!, ,',,c, TOTAL VALUATION:
PLANNING APPL# ❑NO , PLANNING APPROVAL LETTER EICHLER HOME? ❑NO A- rr
By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on a 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-identifi-d prope for ins.ection purposes.
Signature of Applicant/Agent: O Date: t'
SUPPLEMENTAL INFORMATION REQUIRED :''s PLAN`CHECI.TYPE x I, t .: OUTING SLIP: ,..:-.."!,''.2....='7;-
!_New SFD or Multifamily dwellings: Apply for demolition permit for p OVER THE COUNTER ❑ BUILDING PLAN REVIEW
existing building(s). Demolition permit is required prior to issuance of building „`
permit for new building. ❑ EXPRESS n t�PLANNING,PLAN REVIEW l� V.
_Commercial Bldgs: Provide a completed Hazardous Materials Disclosure 0 STANDARDf ,', ,' x ®k PUBLIC WORKS
6 ,� t o- r u,
form if any Hazardous Materials are being used as part of this project. ❑ FIRE DEPT; i _
❑. LARGE;
_Copy of Planning Approval Letter or Meeting with Planning prior to i } '
❑ SANITARYSEWERDISTRICT
submittal of Building Permit application. (0 IVIAaoRh tti ;r i -
.. _ '1'.� ''='''-','',.';'' :,.:!" ❑,i ENVIRONIVIENTAI;HEALTH ..;..
BldgApp_2011.doc revised 06/21/11