B-2017-1785 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2017-1785
10630 JOHANSEN DR CUPERTINO,CA 95014-3509(375 36 010) ANSON 1P
CUPERTINO,CA 95014
OWNER'S NAME: IP ANSON AND IIZUKA EMI DATE ISSUED: 10/18/2017
OWNER'S PHONE:408-221-7887 PHONE NO:(408)221-7887
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class B Lic.#1028300
Contractor ANSON IP Date 06/30/2019 X BLDG X 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:
(N)TEMPORARY POWER POLE(100 AMP)
I hereby affirm under penalty of perjury one of the following two declarations: -
have and will maintain a certificate of consent to self-insure for Worker's
4.00,1
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. Sq.Ft Floor Area: Valuation:$600.00
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 375 36 010
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 e Cupertino Municipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
aturg' ��, Date 10/18/2017 Issued by:Jasmine Archbold
_�. Date: 10/18/2017
OWNER-BUILDER DECLA ••TION
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:10/18/2017
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 25505,2.533,and 25534.
Labor Code,I must forthwith comply with such provisions or this permit shall
be deemed revoked. " J • uthorized agent: !/1/
APPLICANT CERTIFICATION
se e:10/18/2017
I certify that I have read this application and state that the above information is CONSTRUCTION LENDING 1 E V ,
correct.I agree to comply with all city and county ordinances and state laws I hereby affirm that there is a construction lending�,.ency for the performance
• relating to building construction,and hereby authorize representatives of this city of work's far 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 10/18/2017 Professional
PrrAqekt -
CONSTRUCTION PERMIT APPLICATION R w evvi2rAP4 41411
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO CA 95014-3255
:,,-,,," -'94,. (408) 777-3228 • buil din rcu�ertino.orgPEMIT#B-20(4- - `1 9j
CUPERTINO REV# DEF#
❑ NEW CONSTRUCTION ❑ADDITION ❑ALTERATION ❑T.I. ❑MEP ❑RE-ROOF ❑SWIMMING POOL/SPA
PROJECT ADDRESS APN a
t0Co30 30)fVwicQ4A Dv, e.l . c.misolit
OWNER NAME PHONE E-MAIL
STREET ADDRESS CITY, STATE,ZIP
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❑CONTRACTOR NAME ❑{OWNER-BUILDER COMPANY NAME �-p�A r LICENSEINUMBERQ /� LICENSE TYPE11
ISTREET ADDREP� I \ A`� 1`�r71.P/Jl t /I� CITY, �iV7 1 24 IJ O 1.)
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E-MAIL PHONE BUS.LIC#
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❑ARCHITECT ❑OWNER ❑OWNER AGENT 0 CONTRACTOR AGENT 0 ENGINEER 0 DEVELOPER ❑TENANT
CONTACT NAME E-MAIL
STREET ADDRESS CITY,STATE,ZIP PHONE
•
DECRIPTON
Twmf (7.0(- -. i2 \*R*A r< ( o419 try-0
SINGLE-FAMILY/DUPLEX 0 MULTI-FAMILY 0 INDUSTRIAL ❑COMMERCIAL I
EXISTING USE EXISTING SF NEW FLOOR SF PORCH SF DECK SF DEMO SF STORIES# TOTAL NET SF USE TYPE OCC SQ.FT. VALUATION(5)
REMODEL REMODEL KITCHEN REMODEL OTHR GARAGE ❑ATTACHED
BATHROOM SF SF SF SF 0 DETACHED
EXISING YES
EICHLER ❑ YES SECOND STORY ADDITION ❑YES
FIRE SPRINKLERS NO s' NO , ( NO
DWELLING SECOND DWELLING ❑ ES ❑ATTACHED❑DETACHED OTHER
UNITS# UNITADDITON: VNO SF
POOLS! 0 FIBERGLASS 0 VINYL-LINED 0 GUNITE ❑PREFABRICATED
POOL-SF SPA-SF I SPA ATTACHED ❑YES 0 NO I TOTAL-SF
r RE EIVED BY: /y r�I�l TOTAL�Vr�ALUATION:
Commercial or Multi-Family Buildings with Public Swimming Pools reauires Deportment of Environmental Heath approval_ • rl/-\1T i{/ /
RE-RD OFI EXISTING ROOF TYPE: ❑BUILT-UP ROOF❑ASPHALT SHINGLES❑WOOD SHAKES❑WOOD SHINGLES❑TILE OTHER( ECIFY)
REMOVE/REPLACE El NO IF NO PLYWOOD ❑1/2" ❑3/8" PLYWOOD TYPE: PITCH: ROOF CLASS
El YES #OF LAYERS THICKNESS❑5/8" OTHER El 0513 Ill CDX OTHER •12 A
PROPOSED ROOF TYPE:❑BUILT-UP ROOF ❑ASPHALT SHINGLES 0 WOOD SHAKES❑WOOD SHINGLES 0 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 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 inspectio•. rpo •s. I ackn ledge and authorize all information contained on this application form
to be made available for public record. 1
Signature of Applicant/Agent: t_/�:����j/� Date: C�--1.g�� I�i .
SUPPLEMENTAL INFORMATION REQUIRED
*New SFD/Second Dwelling Units/Multifamily Dwellings:A Demolitio !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_20/7.doc revised 08/01/17