B-2017-1933 •
• CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2017-1933
19780 STEVENS CREEK BLVD CUPERTINO,CA 95014-2456(369 06 012) NICHOLS
CONTRACTING INC
VACAVILLE,CA 95687
OWNER'S NAME: EVERSHINE VI,LP DATE ISSUED: 11/13/2017
OWNER'S PHONE:408-343-1088 PHONE NO:(707)718-1181
LICENSED CONTRACTOR'S DECLARATION_ — BUILDING PERMIT INFO:
•
License Class B Lic.#925656
Contractor NICHOLS CONTRACTING INC Date 12/31/2018 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:
GALPAO GAUCHO-CONSTRUCT(N)INTERIOR WALL,NON LOAD
I hereby affirm under penalty of perjury one of the following two declarations: BEARING(25 L.F.)
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.
iti I.have and will maintain Worker's Compensation Insurance,as provided for by
( iiSection 3700 of the Labor Code,for the performance of the work for which this
permit is issued. ,
Sq.Ft Floor Area: Valuation:$2400.00
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 �(unicipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
// Y%,OF // /
Signatur Date 11-13-2017 Issued by: Kim Dunbar
Date: 11/13/2017
P
OW R-BUILDER DECLARATION
I hereby affirm that I ant 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 ownerof 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 offeredfor inspection.
sale(Sec.7.044;Business&Professions Code)
z. I,as owner of theproperty,am exclusively contracting with licensed Signature of Applicant:
contractorsito construct the project(Sec.7044,Business&Professions Code). Date: 11-13-2017
1 hereby affirm tinder 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
I
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 andlwill maintain Worker's Compensation Insurance,as provided for by I have read the hazardous materials requirements under Chapter 6.95 of the
Section 37„00 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
i 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 534.
Labor Code,I must forthwith comply with such provisions or this permit shall I%
be deemed revoked. Owner or authorized agent
APPLICANT CERTIFICATION Date:11-13-2017 '
I certify that I have read this application and state that the above information is CONST I'' CTION LENDING AGENCY
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 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.
it .
Licensed
Signature Date 11-13-2017 Professional
LVA\V 11\V-`11V1• l L111T111 All LCALAI
/// COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO,CA 95014-3255
^S 19
, may' ss (408)777-3228 • building@cupertino.org PEMIT#B= 20(1 - (9.S3
CUPERTINO. REV# DEF#
,Q NEW CONSTRUCTION Q ADDITION El ALTERATION CI T.I. ❑MEP Q RE-ROOF,., D SWIMMING POOL/SPA ;
PROJECF ADiSarss 19780 Stevens Creek Blvd. [AIuN a 369-06-012
OWNER NAME PHONE E-MAIL,
Utir hi r1 \I I ..r /0g-343-1 O$g N A
0STREET ADDRESS CI ,STATE,Z P
if, ►�1,2a shim 61 u Lt.2 (U9f'-( aI (A '?5O14 •
I RI CONTRACTOR NAME / CE NUMBER LICEN', TYPE •
0OWNER-BUILbER COMPANY NAME LI NSE
. is 6�5 ick.al5 f �iL4Mc. d �2 / /
' STREET ADDRESS C STATE. 1
IO�� NoO,l�i /4 Dr. e i ii e .>5 /S7
' E-MAIL PHONE - BUS. C
N/� I1-04- gig-I !S1 D U 3! .
0 ARCHITECT 0 OWNER DOWNER AGENT 0 CONTRACTOR AGENT❑'ENGINEER❑DEVELOPER 0 TENANT
CONTACT NAME E-MAIL
Robert Juarez,Form Studio Archit. robert@formstudioarc.com
STREET ADDRESS CITY,STATE,ZIP PHONE
. '234 Soscol Ave-,#206 Napa,CA 94559 ' - (707)337-2255
' Tenant: Galpao Gaucho. New interior wall,non-load bearing.
.❑SINGLE-FAMILY/DUPLEX ❑MULTI-FAMILY ❑INDUSTRIAL 0 COMMERCIAL
EXIS'T'ING USE EXISTING SF NEW FLOOR SF PORCH SF DECK SF DEMO SF STORIES:. TOTAL NEr SE USE TYPE OCC SQ.FT. VALUATION($)
REMODEL REMODEL KITCHEN REMODEL OTHR GARAGE. ❑ATTACHED
BATHROOM SF SF SF SF 0 DETACHED
EXISING _ DYES PITHIER CI YES SECOND STORY ADDITION ❑YES i
FIRE SPRINKLERS❑NO 0 NO 0N
DWELLING SECOND DWELLING ❑YES 0ATTACHED❑DETACHED OTHER
UNITS I IUNIT AMNTON: ❑NO S F
POOLS' ❑.FIBERGLASS ❑=VINYL-LINED 0GUNITE 0 PREFABRICATED
POOL-SF SPA-SF l SPA ATTACHED❑YES 0 NO j TOTAL-SF '
REd B TOTAL VALUATION:
Guunmrcinl or M+dfr-Fnv+ilj.BuiJdings.with Public S:vin+n+r"r+g Pools requires Deportment of Eimirnmue++tnl Hrnlh.nvuroiml -
' - RE-ROOFI EXISTING ROOF TYPE: El BUILT-UP ROOF 0 ASPHALT SHINGLES]WOOD SHAKES Q WOOD SHINGLES UTILE OTHER(SPECIFY)
REMOVE/REPLACE 0 NO IF NO PLYWOOD ❑ El 3/8" PLYWOOD TYPE: PITCH: ROOF CLASS
.12
DYES F OF LAYERS THICKNESS 0 5/8" OTHER IDOSB ElCDX OTHER 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 :Eof 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 in section purposes: I acknowledge and authorize all information contained on this application form -
to be made available for public record.
Signature of Applicant/Agent: /A *AI • - C'. Date: Ii-404 '1
SUPPLEMENTAL INFORMATION i e UIRED
*New SFD/Second Dwelling Units/Mu rifamily Dwellings:A 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 '
3IdgApp„2017.doc revised`08/ 01/17