B-2017-1828 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2017-1828
21373 DEXTER DR CUPERTINO,CA 95014-1316(326 41 087) AAA ELECTRIC •
SAN JOSE,CA 95121
OWNER'S NAME: CHAMBERLAIN PARK AND JOAN B TRUSTEE 'DATE ISSUED: 10/25/2017
OWNER'S PHONE:408-365-3806 PHONE NO:(408)557-8899
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class C-10 Lic.#741094
Contractor A AA ELECTRIC Date 10/31/2017 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
licenseis in full force and effect. JOB DESCRIPTION:
INSTALL 8 LIGHT FIXTURES;3 CIRCUITS(20 AMPS)-KITCHEN
I hereby affirm under penalty of perjury one of the following two declarations:
i. I have and will maintain a certificate of consent to self-insure for Worker's
Cs.:rpensation,as provided for by Section 3700 of the Labor Code,for the
, tE ance of the work for which this permit is issued.
e 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 isued. Sq:Ft Floor Area: Valuation:$4000.00
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 326 41 087
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 C'ty in'consequence of the granting of this permit. WITHIN 180 DAYS OF PERMIT ISSUANCE OR
Additionally,the applican nderstands and will comply with all non-point
source regulation,.-: : Cu.erino Municipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
' natur / ' _ Date 10/25/2017 Issued by:Abby Ayende •
• Date: 10/25/2017 •
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
I. I,as owner of the propeity,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(See.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: 10/25/2017
I hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
i. 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
material. Additionally,should I use equipment or devices which emit hazardous
shall not employ any person in any manner so as to become subject to the I
air contaminants as defined by the Bay Area•it Quality Management District I
Worker's Compensation laws of California. If,after making this certificate of will maintain compliance with the C p= i /Municipal Code,Chapter 9.12 and
exemption,'I become subject to the Worker's Compensation provisions of the • the Health&Safety Cod:, :ec•a ,,550 ..33,and 25534.
Labor Code,I must forthwith comply with such provisions or this permit shall
be deemed revoked. i ner or authorized agen .
APPLICANT CERTIFICATION dl.trDate:10/25/2017
I certify that I have read this application and state that the above information is a,-T' T S►LEiDI►
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 thiscity of work's for which this permit is issued(Sec.3097,Civ C.) .
I to enter upon the above mentioned property for inspection purposes. (We)agree Lender's Name
I to saveindemnify 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 10/25/2017 Professional
CONSTRUCTION PERMIT APPLICATION _
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
rit94.• NI -
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
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5 rr (408) 777-3228 • building@cuPertinaorg PEMIT#13-
CUPERTINO REV# DEFE
❑ NEW CONSTRUCTION ❑ (Q
ADDITIOONN}�❑ALTERATION111❑T.I. ❑MEP ❑RE-ROOF SWIMMING POOL/SPA
PROJECT ADDRESS I e--- --(3r'/�v...___/\ � e1\ ' APN i iY ^ (1 03
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E-MAIL a "PHO j S� BUS.LIC P /
❑ARCHITECT 0 OWNER,❑OWNER AGENT 0 CONTRACTOR AGENT ENGINEER 0 DEVELOPER 0 TENANT
CONTACT NAME E-MAIL
STREET ADDRESS CITY,STATE,ZIP PHONE
DECRIPTON
•
C., -- 4>trGds r -�
. , . 5 3 _ r J2„, (/ocr -(1,c6,77- To f
, INGLE-FAMILY/DUPLEX 0 MULTI-FAMILY ' 0 INDUSTRIAL 0 COMMERCIAL I
EXISTING USE EXISTINGSF NEW FLOOR SF ,PORCH SF DECK SF DEMO SF STORIES P TOTAL NET SF USE TYPE OCC SQ.FT. VALUATION(5)
.
REMODEL ,i !REMODEL KITCHEN REMODEL OTHR GARAGE 0 ATTACHED
BATHROOM.SF 'SF - SF SF - 0 DETACHED
EXISING ID YES!,,,EICHLER ❑'YES SECOND STORY ADDITION DYES
FIRE SPRINKLERS 0 NO'i Vii'' .❑,NO 0 NO
, DWELLING .'SECOND DWELLING D YES 0 ATTACHED❑DETACHED OTHER
UNITSP 1 UNITADDITON:, 0 NO SF
i
POOLS i i0'FIBERGLASS 0 VINYL-LINED ❑GUNITE 0 PREFABRICATED
POOL-SF SPA-=SFI ' I SPA ATTACHED DYES 0 NO I TOTAL-SF
RECEIVED VALUATION:
Comiurrciulor,Mulli-Family Buildings with Public Stuinuaing Pools requires Department of Environmental Heath approvalc ITOT&L
(4Jn r)
RE-ROOF EXISTING ROOF TYPE: ❑BUILT-UP ROOF❑ASPHALT SHINGLES D WOOD SHAKES E WOOD SHINGLES❑TIL OTHER(SPECIFY)
REMOVE/REPLACE 0 NO IF NO PLYWOOD D 1" E 3/8" PLYWOOD TYPE: PITCH: ROOF CLASS
D yEs P OF LAYERS THICKNESS❑5/8" OTHER ❑OSB ❑CDX OTHER •12 A
PROPOSED ROOF TYPE:❑BUILT-UP ROOF ❑ASPHALT SHINGLES 0 WOOD SHAKES DWOOD SHINGLES 0 OTHER
*Provide a signed copy of the Cupertino's Tear-Off Policy SF Psi 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,.rovided is correct. I'have read the Description of Work and verify it is accurate. I agree
to comply with all applicable local ordin .e-s :,dr . - :