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B-2017-2180 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: CONTRACTOR. PERMIT NO.B-2017 2180 20415 VIA PAVISO CUPERTINO,CA 95014-6322(316 01 219) GALLAHER COMPANY SAN JOSE,CA 95133 OWNER'S NAME. HS VENTURES LLC DATE ISSUED•12/19/2017 OWNER'S PHONE:408-292-0966 PHONE NO:(408)825-1362 LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO• License Class C-36 Lic.#946359 Contractor GALLAHER COMPANY',Date 02/28/2018 X BLDG —ELECT X 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)40 GAL WATER HEATER-SAME LOCATION 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. I have and will maintain Worker's Compensation Insurance,as provided for by pat Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. Sq.Ft Floor Area. Valuation:$2417.00 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 316 01 219 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 againstsaidCity in stands andce of the hg othis WITHIN 180 DAYS OF PERMIT ISSUANCE OR Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION Signature Date 12/19/2017 Issued by•Jasmine Archbold Date: 12/19/2017 OW R 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 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:12/19/2017 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 a. 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 ofCalifornia. 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 25534. Labor Code,I must forthwith comply with such provisions or this permit shall l yam,. be deemed revoked. Owner or authorized agent:_ __ APPLICANT CERTIFICATION Date:12/19/2017 �� I certify that I have read this application and state that the above information is CON `I'RUCT.I N 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. Signature Date 12/19/2017 LicenseProfessionald CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISIONB , 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 44-1p,.. - (408) 777-3228 • building@cupertino.org PEMIT PB- X01 — Z180 CUPERTINO REV# DEF n ❑ NEW CONSTRUCTION ❑ADDITION ❑ALTERATION ❑T.1. ❑MEP ❑RE-ROOF ❑SWIIvUVIING POOL/SPA PROJECT Z09 /5 ii i. et PmV5a(? 4-3d / iA —lo APNp 396- d1 - 2t9 OWNER NAME 'PHONE E-MAIL Le al - 'mcg n e�-� 2e n 90,6- 2.,2 - ®It/ c, tirro I(e 1 4,4.- ralrt er4G0 STREET DRESS CITY, STATE,ZIP 4:1"S33 (,) 0.-) �- )6 ..t- /Zit) .,*-) 3 0s2e v 9-‘7)'D D ❑CONTRACTOR NAME D OWNER-BUILDER COMPANY NAME LICENSE NUMBER LICENSE TYPE GCa((ai?ee" CV dgt3t ! t7F?:ar 9,-,4;,7 q C & 3.3--1 c s Y STREET ADDRESS //1� j / / CITY,STATE, ZIP /� 6-C1,33 y ! I 2 2 G d - fT 7` a`^el C-�"t" PHONE .%t//+7 j©se „ c71- l-C/ E-MAIL BUS.LIC r io -COC^ 11-'0 �d,o n , corn Yd Q- �";— X337 14c). 7 ?D 0 ARCHITECT 0 OWNER.❑OWNER AGENT ❑CONTRACTOR AGENT 0 ENGINEER❑DEVELOPER 0 TENANT CONTACT NAME E-MAIL STREET ADDRESS CITY,STATE,ZIP PHONE DECRIPTON / MI , V�/©i Zf .ci F G r n 2 (BY c�n2�f2 J d St"�' LGo ✓.c�'!t • ❑SINGLE-FAMILY/DUPLEX `LMULTI-FAMILY 0 INDUSTRIAL 0 COMMERCIAL I EXISTING.USE EXISTING SF NEW FLOOR SF PORCH SF DECK SF DEMO SF STORIES.A TOTAL NET SF USE TYPE OCC SQ.FT. VALUATION(5) REMODEL REMODEL KITCHEN REMODELOTHR GARAGE 0 ATTACHED BATHROOM SF SF SF SF 0 DETACHED EXISTNG DYES ❑EICHLER 0 YES SECOND STORY ADDITION YES FIRE SPRINKLERS 0 NO 0 NO 0 NO DWELLING SECOND DWELLING DYES 0 ATTACHED DETACHED OTHER UNITS„ UNITADDITON: ❑NO SF POOLS ❑FIBERGLASS ❑VINYL-LINED 0 GUNITE 0 PREFABRICATED POOL-SF SPA-SF 1 SPA ATTACHED ❑YES 0 NO I TOTAL-SF RECE Commercial or Multi-Family Buildings with Public Swimming Pools requires Department ofEuoirarvuental Heath approval �If _ L�V,jLj-iO: RE-ROOF EXISTING ROOF TYPE: 0 BUILT-UP ROOF❑ASPHALT SHINGLES❑WOOD SHAKES❑WOOD SHINGLES❑TILE OTHER(SPECIFY) REMOVE/REPLACE D NO IF NO PLYWOOD 01/2" 03/8" PLYWOOD TYPE: PITCH: ROOF CLASS. ❑YES r OF LAYERS THICKNESS❑5/8" OTHER 0 OSB 0 CDX OTHER :12 A PROPOSED ROOF TYPE:❑BUILT-UP ROOF DASPHALT SHINGLES ❑WOOD SHAKES❑WOOD SHINGLES D OTHER "Provide a signed copy of the Cupertino's Tear-Off Policy SF of 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 fo - spectios .osey I acknowledge and authorize all information contained on this application form to be made available for public rec. d r 7�� Signature of Applicant/Agent: / Date: I7- l/ _ SUPPLEMENTAL INFORMA 0 E•'UI • "New SFD/Second Dwelling U :,s/Multifamily Dwellings:ADemolition 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 BIdgApp_2017.doc revised 08/01/17