B-2017-0748
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: - CONTRACTOR: PERMIT NO:B-2017-0748 •
10630 JOHANSEN DR CUPERTINO,CA 95014-3509(375 36 010) ANSON IP
• CUPERTINO,CA 95014
OWNER'S NAME: IP ANSON AND IIZU DATE ISSUED: 11/21/2017
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 —ELECT —PLUMB
I hereby affirm that I am licensed under the provisions of Chapter 9(commencing —MECH X RESIDENTIAL_COMMERCIAL
with Section 7000)of Division 3 of the Business&Professions Code and that my
license is in full force and effect. JOB DESCRIPTION:
(N)SINGLE STORY SFD(2112 SF);ATTACHED GARAGE(431 SF);
I hereby affirm under penalty of perjury one of the following two declarations: PORCH(600 SF);DECK(118 SF);
1. I have and will maintain a certificate of consent to self-insure for Worker's
csmpensation,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
a,` Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued. Sq.Ft Floor Area:2112 Valuation:$380000.00
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 td building construction,and hereby authorize 375 36 010 R-3(Custom)
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
sourc regulations pe = uperti '. Municipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
,I . . i
Signature meMiA Date 11/21/2017 Issued by:Abby Ayende
ow, Date: 11/21/2017
OWNER-BUILDER DECLARA I'ON
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. • .1,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: 11/21/2017 ,
I hereby affirm,under penalty of perjury one of the following three declarations: „ „
1. • I-have and will maintain a Certificate of Consent to self-insure for Worker's ALL ROOF COVERINGS TO BE CLASS A OR BETTER
•'Compensation,as provided for by Section 3700 of the Labor Code,for the
performance of tfie 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
Health&Safety Code,Section 25532(a)should I store or handle hazardous
3. I'cetfifylthat in the performance of the work for which this permit is issued,I 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 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&SafetyCode,Se 25505/5533,and 25534.
Labor Code,I must forthwith comply with such provisions or this permit shall
be deemed revoked. � ���//�//
Date: 11/21/2017
-,I caner or authorized agent4j ,-
APPLICANT CERTIFICATION .
I certify that I have read this application and state that the above information is I - R Tie LE DI • EN V
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
aridi 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 11/21/2017 Professional -
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO: B-2017-0748
10630 JOHANSEN DR CUPERTINO, CA 95014-3509 (375 36 010) ANSON IP
CUPERTINO, CA 95014
OWNER'S NAME: IP ANSON AND IIZUKA EMI
OWNER'S PHONE:
LICENSED CONTRACTOR'S DECLARATION
License Class B Lic. #1028300
Contractor ANSON IP Date 06/30/2019
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.
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
DATE ISSUED: 11/21/2017
PHONE NO: (408) 221-7887
BUILDING PERMIT INFO:
X BLDG —ELECT —PLUMB
_ MECH X RESIDENTIAL_ COMMERCIAL
JOB DESCRIPTION:
(N) TWO STORY SFD (2112 SF); ATTACHED GARAGE (431 SF);
PORCH (5 81 SF); DECK (118 SF);
REV#1 - LANDSCAPE DESIGN - ISSUED 9/25/18
REV#2 - REVISION TO ELEVATION AND FURNACE AREA -ISSUED
performance of the work for which this permit is issued.10-1-2018
z. 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.
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
and state laws relating to building construction, and hereby authorize
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
may accrue against said City in consequence of the granting of this permit.
Additionally, the applicant understands and will comply with all non -point
source regulations
I hereby affirm that I am exempt from the Contractor's License Law for one of the
following two reasons:
1. I, as owner of the property, or my employees with wages as their sole
compensation, will do the work, and the structure is not intended or offered for
sale (Sec.7044, Business & Professions Code)
z. I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec.7044, Business & Professions Code).
I hereby affirm under penalty of perjury one of the following three 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.
z. 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.
a. I certify that in the performance of the work for which this permit is issued, I
shall not employ any person in any manner so as to become subject to the
Worker's Compensation laws of California. If, after making this certificate of
exemption, I become subject to the Worker's Compensation provisions of the
Labor Code, I must forthwith comply with such provisions or this permit shall
be deemed revoked.
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 and state laws
relating to building construction, and hereby authorize 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 may accrue against said City in
consequence of the granting of this permit. Additionally, the applicant understands
and will comply with all non -point source regulations per the Cupertino Municipal
Code, Section 9.18.
Date 10-1-2018
Sq. Ft Floor Area: 2112 1 Valuation: $380000.00
APN Number: Occupancy Type:
375 36 010 1 R-3 (Custom)
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
Issued by: Abby Ayend
Date: 11/21/2017
RE -ROOFS:
All roofs shall be inspected prior to any roofing material being installed. If a roof is
installed without first obtaining an inspection, I agree to remove all new materials for
inspection.
Signature of Applicant:
Date: 10-1-2018
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
HAZARDOUS MATERIALS DISCLOSURE
I have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533, and 25534. I will
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
Health & Safety Code, Section 25532(a) should I store or handle hazardous
material. Additionally, should I use equipment or devices which emit hazardous
air contaminants as defined by the Bay Area Air Quality Management District I
will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and
the Health & Safety Code, Sections 25505, 5533, and 25534.
Owner or authorized agent:
Date: 10-1-2018
N TR I LEENCY
I hereby affirm that there is a construction lending ency for the performance
of work's for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
Lender's Address
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Licensed
Professional
M Fit FOR RECORDING PURSUANT TO
GOVERNMENT CODE SECTION 27383
When Recorded Mail To:
City of Cupertino
Community Development Department
10300 Torre Avenue
Cupertino, CA 95014
Regina A l oomendras
Santa Clara County - Clerk -Recorder
09/28/2.018 08:32 AM
Titles: I Pages: 3
Fees:10.00
0.00
Taxes: 0
Total:
III ��dY ®�®� 10 11YOUTIMI h, VX 1A ®III
that the following plantings shall be maintained as privacy and protected trees to screen the views from the
second floor: three (3) Arbutus Marina along the rear (eastern) propertyline, seven (7) Italian Cypress (Cupressus
sempervirens) along the northern side property line, and eight (8) Italian Cypress (Cupressus sempervirens) along
the southern side property line. In addition to the privacy' plantings; the following plant.m. & shall be mam,dined
as the required front yard tree in the front yard setback: one (1) Tuscarora Crape Myrtle (Lagerstroen is indica
'Tuscarora'). In the event these plantings die, the owner(s) shall provide replacement planhngs'subject to the
approval of the City of Cupertino. This declaration is binding on the successors and assignees of the owners(s).
PROPERT WNE (S):
Own 's Signature
Print Owner's Name
q-
Date
CITY;A;UTHORIZA 110N:
Jeffrey sumura, Assistant Planner
CALIFORNIA i; s 41* ti ACKNOWLEDGMENT
,
{�iyour®y d r� t y'!x _
A notary public or other officer completing this certificate verifies only the identity of the individual who signed the document to
which this certificate is attached, and not the truthfulness, accuracy, or validity of that document.
State of California
County of �� , �t C�4
On before me, ( fl --f e C 12-L, c� Y C4 S , Notary Public,
(Here insert name and title of the officer)
personally appeared
>° -(�� y / u Pt u,,-
who
,,
who proved to me on the basis of satisfactory evidence to be the persono whose named is/are subscribed to
the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized
capacityp.,ds), and that by his/her/their signatures on the instrument the person, or the entity upon behalf of
which the person acted ecuted the instrument.
I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph
is true and correct.
KIR STEN RENEE SQUARCIA
Commission ; 208,0884
a - �� rotary Public - California z
WITNESS my hand and official seal. z =
Santa Clara County n
my comm. Ex ices Oct 4 2018.
(Notary Seal)
Signature of Notary Public
ADDITIONAL OPTIONAL INFORMATION
MATION
INSTRUCTIONS FOR COMPLETING THISFORM.
Any acknowledgment completed in California must contain verbiage exactly as
appears above in the notary section or a separate acknowledgment form must be
properly completed and attached to that document. The only exception is if a
document is to be recorded outside of California. In such instances, any alternative
acknowledgment verbiage as may be printed on such a document so long as the
verbiage does not require the notary to do something that is illegal fora notary in
California (i.e. certifying the authorized capacity of the signer).' Please check the
document carefully for proper notarial wording and attach this form if required.
o State and County information must be the State and`County where the document
signer(s) personally appeared before the notary public for acknowledgment.
• Date of notarization must be the date that the signer(s) personally appeared which
must also be the same date the acknowledgment isl completed.
m The notary public must print his or her name as it appears within his or her
commission' followed by a comma and then your title (notary, public).
o Print the name(s) of document signer(s) who personally appear at the time of
notarization.
o Indicate the correct singular or plural forms by crossing, off incorrect forms (i.e.
he/she/ is /are ) or circling the correct forms. Failure to correctly indicate this
information may lead to rejection of document recording.
a The notary seal impression must be clear and photographically reproducible.
Impression must not cover text or lines. If seal impression smudges, re -seal if a
sufficient area permits, otherwise complete a different acknowledgment form.
a Signature of the notary public must match the signature on file with the office of
the county clerk:'
Additional infonnation is not required but could help to ensure this
acknowledgment is not misused or attached to a different document.
Indicate title or type of attached document, number of pages and date.
4• Indicate the capacity claimed by, the signer. If the claimed capacity is a
corporate officer,indicate the title (i.e. CEO, CFO, Secretary).
o Securely attach this document to the signed document
DESCRIPTION OF THE ATTACHED DOCUMENT
(Title or description of attached document)
(Title or description of attached document continued)
Number of Pages Document Date
(Additional information)
CAPACITY CLAIMED BY THE SIGNER
❑ Individual (s)
❑ Corporate Officer
(Title)
❑ Partner(s)
❑ Attorney -in -Fact
❑ Trustee(s)
❑ Other
C 2004-2015 ProLink Signing Service, Inc. — All Rights Reserved www.TheProLink.com — Nationwide Notary, Service
SFBayNotilry.com
A notary public or other officer completing this certificate verifies only the identity of the individual
who signed the document to which this certificate is attached, and not the truthfulness, accuracy, or
validity of that document.
State of California
County of Santa Clara
On 01 before me, R.C. Singh, Notary Public,
Date
Name and Title of Officer
personally appeared
i ll<
who proved to me on the basis of satisfactory
evidence to be the person(s) whose name(s)
is/are subscribed to the within instrument and
acknowledged to me that he/she/they
executed the same in his/her/their authorized
capacity(ies), and that by his/her/their
signature(s) on the instrument the person(s),
or the entity upon behalf of which the
R C.: S:INGH
Notaq Public California
person(s) acted, executed the instrument.
Z .` . o Santa Clara. County
z
Corimissibn # 2127652n
My Comm Expire's Oct
I certify under PENALTY OF PERJURY
,�. 2T.,,2019
. under the laws of the State of California that
the foregoing paragraph is true and correct.
WITNESS my hand and official seal
Signature o tary Public
My Commission ]Expires: Oct 21, 2019
OPTIONAL INFORMATION
Title or Type of Document:
Document Date:
Number of Pages:
Capacity of Signer:
SFBayNotilry.com
iNO FEE FOR RECORDING PURSUANT TO
GOVERNMENT CODE SECTION 27383
When Recorded MaH To:
City of Cupertino
Community Development Department
10300 Torre Avenue
Cupertino, CA 95014
24032608
Regina A l comendras
Santa Clara County - Clerk -Recorder
09/28/2018 08:32 AM
Titles: I Pages: 3
Fees: 0.00
Taxes: 0
Total: 10.00
Bill KA170 W W 114"d 41.0814W CA '11111
SFBk�yNotaryxom
A notary public or other officer completing this certificate verifies only the identity of the individual
who signed the document to which this certificate is attached, and not the truthfulness, accuracy, or
validity of that document.
State of California
County of Santa CRara
On ()fl7VI-0�6 before me, R.C. Singh, Notary Public,
Date Name and Title of Officer
personally appeared A -Ar -f cAl
who proved to me on the basis of satisfactory
evidence to be the person(s) whose name(s)
is/are subscribed to the within instrument and
acknowledged to me that he/she/they
executed the same in his/her/their authorized
capacity(ies), and that by his/her/their
signature(s) on the .'instrument the person(s),
R.. C. SINGH 'N or the entity upon behalf of which the
, i.f -- I person(s) acted, executed the instrument..
*br-California
.11 y Pub - Ga i ornia.
z 54rita Clara. county z
Co- ' i s�s r
m M .on # 2127652 D1 certify under PENALTY OF PERJURY
My Comm, UpWls Oct 217,,2019 under the laws of the State of California that
the foregoing paragraph is true and correct.
WITNESS my hand and official seal
SignaW-ffie'of Notary Public
My Commission Expires- Oct 21, 2019
OPTIONAL INFORMATION
Title or Type of Document:
Document Date:
Number of Pages:
Capacity of Signer:
SFBk�yNotaryxom
A notary?public or other officer completing this certificate verifies only the identity of the individual who signed the document to
which this certificate is attached, and not the truthfulness, accuracy, or validity of that document.
State of California
County of 14 h 4"�, C/ a r -"�
On �• 27 t°d' before me, ki i -C e -ti e e d L/ e ei Notary Public,
(Here insert name and title of the officer)
personally appeared e �'�
9
who proved to me on the basis of satisfactory evidence to be the person whose name(srs/are subscribed to
the within instrument and acknowledged to me .that he/she/they executed the same in his/her/their authorized
capacity(, and that by his/her/their signatureW on theinstrument the personko, or the entity upon behalf of
which the person acted, executed the instrument.
I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph
is true and correct.
KIRSTEN RENEE.SQ0ARCIA
Commission. �# 20,0984
WITNESS myhand and official seal. Z .� ®o (votary Public -California D
Santa Clara County
M Comm Ex' res.Oct 4, 201$.
(Notary Seal)
Signature of Notary Public
r_e������i�iric��r_�irr����i�ic��r_aiw�ir�r��i:�► r�i��r��►i
DESCRIPTION OF THE ATTACHED DOCUMENT
(Title or description of attached document)
(Title or description of attached document continued)
Number of Pages Document Date
(Additional information)
CAPACITY CLAIMED BY THE SIGNER
❑ Individual (s)
❑ Corporate Officer
(Title)
❑ "Partner(s)
❑ Attorney -in -Fact
❑ Trustee(s)
❑ Other
INSTRUCTIONS FOR COMPLETING THIS FORM
Any acknowledgment completed in California must contain verbiage exactly as
appears above in the notary section or a separate acknowledgment form: must be
properly completed and attached to that document. The only exception is if a
document is to be recorded outside of California. In such instances, any alternative
acknowledgment verbiage as may be printed on such a document so long': as the
verbiage does not require the notary to do something that is illegal for a notary in
California (i.e. certifying the authorized capacity of the signer). Please check the
document carefully for proper notarial wording and attach this form if required.
o State and County information must be the State and County where the document'
signer(s) personally appeared before the notary public for acknowledgment.
o Date of notarization must be the date that the signer(s) personally appeared which
must also be the same date the acknowledgment is completed.
o The notary public must print his or her name as it appears within his or her
commission followed by a comma and then your title (notary public).
m Print the name(s) of document signer(s) who personally appear at the time of
notarization.
® Indicate the correct singular orpluralforms by crossing off incorrect forms (i.e.
he/she/Vaey,- is /are ) or circling the correct forms. Failure to correctly indicate this
information may lead to rejection of document recording.
o The notary seal impression must be clear and photographically reproducible.
Impression must not cover text or lines. If seal impression smudges,, re, -seal if a
sufficient area permits, otherwise complete a differentacknowledgment form.
o Signature of the notary public must match the signature on file with the office of
the county clerk.
Additional information is not required but could help to ensure this
acknowledgment is not misused or attached to,a different document.
Indicate title or type of attached document, number of pages and date.
Indicate the capacity, claimed by the signer. If the claimed capacity is a
corporate officer, indicate the title (i.e: CEO, CFO, Secretary).
o Securely attach this document to the signed document
C 2004-2015 ProLink Signing Service, Inc. — All Rights Reserved www.TheProLink.com — Natiomvide Notary Service