B-2017-1653 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2017-1653
7572 KIRWIN LN CUPERTINO,CA 95014-4339(359 22 026) HOME WORKS
CONSTRUCTION INC
SAN JOSE,CA 95129
OWNER'S NAME: MATSUZUKA SHINOBU AND KANAKO DATE ISSUED:09/25/2017
OWNER'S PHONE:408-861-0337 PHONE NO:(408)850-6477
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class ja Lic.#949598
Contractor HOME WORKS CONSTRUCTION INC Date 08/31/2018 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-(80 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.
c),,
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. Sq.Ft Floor Area: Valuation:$8000.00
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 359 22 026
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..asequence of the granting of this permit. WITHIN 180 DAYS OF PERMIT ISSUANCE OR
Additionally,the appli nt undo .tands and will comply with all non-point
source regulation . �th- f rtino Municipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
d
y, '�Signatur-, � 'I� L Date 09-25-2017 Issued by:Kim Dunbar
��l Date:09/25/2017
• . .. i-, 1 t 1 ell : .. s.
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:09-25-2017
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 equip •nt or devices w ich emit hazardous
air contaminants as defined by the Bay A- a Air Quality :nagement District I
Worker's Compensation laws of California. If,after making this certificate of will maintain compliance with the Cu. `; o Municipal ♦.de,Chapter 9.12 and
exemption,I become subject to the Worker's Compensation provisions of the the Health&Safety Code f i f Z?r,25 .3,an. 5534.
Labor Code,I must forthwith comply with such provisions or this permit shall / i /
be deemed revoked. Owner or authorized agen ,_ L.1 —lit"'
APPLICANT CERTIFICATION Date:09-25-2017
I certify that I have read this application and state that the above information is a I t a E Mt '•/: k
correct.I agree to comply with all city and county ordinances and state laws I hereby affirm that there is a construction le 'ing 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. I understand my plans shall be used as public records.
Licensed
Signature Date 09-25-2017
Professional
CONSTRUCTION PERMIT APPLICATION
(,...
..v/ COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISIONB
10300 TORRE AVENUE • CUPERTINO,CA 95014-3255
4,yt.rvs, 0 1" - l (0073(408)777-3228 • building@cupertino.or� PEMIT#B-
CUPERTINO REV# DEF#
CTA❑ NEW CONSTRUCTION. ❑ADDITION ALTERATION 1=1T.I. I=1 MEP LIRE-ROOF ❑SWIMMING POOL/SPA
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E-MAIL PHONE/ �5O 6� IBUS.LIC S
0 ARCHITECT 0 OWNER ❑OWNER AGENT 0 CONTRACTOR AGENT ENGINEER 0 DEVELOPER 0 TENANT
CONTACT NAME E-MAIL
STREET ADDRESS CITY,STATE,ZIP PHONE
DECRIPTON 2.410,...,e.--
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yINGLE-FAMILY/DUPLEX 0 MULTI-FAMILY 0 INDUSTRIAL ❑COMMERCIAL I
EXISTING USE EXISTING SF NEW FLOOR SF PORCH SF DECK SF DEMO SF STORIES S TOTAL NET SF USE TYPE OCC SQ.FT. VALUATION($)
REMODEL REMODEL KITCHEN REMODEL OTHR GARAGE ❑ATTACHED
BATHROOM SF SF go SF SF 0 DETACHED
EFIREISPRINKLERS 0 NO EICHLER NG 0 YES ❑ NO❑YES SECOND STORY ADDITION 0 YES
NO
DWELLINGI SECOND DWELLING ❑YES 0 ATTACHED❑DETACHED OTHER
UNITS S UNIT ADDITON: ❑NO S F
POOLS' ❑FIBERGLASS ❑VINYL-LINED ❑GUNITE ❑PREFABRICATED I
POOL-SF SPA-SF I SPA ATTACHED❑YES 0 NO I TOTAL-SF
RE B i. •T.VALUATION:
Commercial or Multi-Family Buildings with Public Swimming Pools requires Department of Environmental Heath approval D ♦ CM
RE-ROOFI EXISTING ROOF TYPE: ❑BUILT-UP ROOF El ASPHALT SHINGLES❑WOOD SHAKES❑WOOD SHINGLES❑TILE OTHER(SPECIFY)
REMOVE/REPLACE❑NO IF NO PLYWOOD El le ❑3/8" PLYWOOD TYPE: PITCH: ROOF CLASS
0 YEsI S OF LAYERS THICKNESS El 5/8" OTHER ❑OSB El CDX OTHER .12 A
PROPOSED ROOF TYPE:❑BUILT-UP ROOF ❑ASPHALT SHINGLES 0 WOOD SHAKES:WOOD SHINGLES ❑OTHER
*Provide a signed copy of the Cupertino's Tear-Off Policy SF Sof 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 pro ' ed is correct. I have read the Description of Work and verify it is accurate. I agree
• to comply with all applicable local ordinances . d stat4 s rela i g to building construction. I authorize representatives of Cupertino to
enter the above-identified property for 4 ''
pur. :. ac. owegeand authorize all information c tain on this application form
to be made available for public record. / /�Signature of Applicant/Agent: I IN Date: _/
SUPPLEMENTAL INFORMATION REQUIRED /
*New SFD/Second Dwelling Units/Multifamily Dwellings: • l emolition permit is required prior to issuance of a building permit for all new construction.
*Commercial Buildings: Provide a completed Hazardous aterials 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 08/01/17