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B-2017-2187CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 11032 CANYON VISTA DR CUPERTINO, CA 95014-5405 (356 28 037) OWNER'S NAME: OWNER'S PHONE: LICENSED CONTRACTOR'S DECLARATION License Class 'Lic. # Contractor OWNER BUILDER Date 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: t. 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. APPLICANT CERTIFICATION I certify that 1 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. CONTRACTOR: PERMIT NO: B-2017-2187 OWNER BUILDER DATE ISSUED: 01/04/2018 PHONE NO: BUILDING PERMIT INFO: X BLDG —ELECT _ PLUMB _ MECH X RESIDENTIAL _ COMMERCIAL JOB DESCRIPTION: BATHROOM REMODEL (432 S.F.); CONSTRUCT (N) WALK IN CLOSET AND REMODEL LAUNDRY CLOSET (103 S.F.) Sq. Ft Floor Area: Valuation: $50000.00 APN Number: Occupancy Type: 356 28 037 PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTION. Signature Date 1/4/2018 I Issued by: Abby Ayende 0112C I• I «. I s. 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 owner of the property, am exclusively contracting with licensed Signature of Applicant: contractors to construct the project (Sec.7044, Business & Professions Code). Date: 1/4/2018 I hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS "A" OR t. 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. 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 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 8. Date 1/4/2018 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 Date: 1/412018 CONSTRUCTION LENDING AGENCY hereby affirm that there is a construction lending agency 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 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2017-2187 11032 CANYON VISTA DR CUPERTINO,CA 95014-5405(356 28 037) GREEN CIRCLE CONSTRUCTION INC BERKELEY,CA 94705 OWNER'S NAME: DATE ISSUED:01/04/2018 OWNER'S PHONE: PHONE NO:( LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: License Class GENERAL BUILDING CONTRACTOR Lic.#936581 Contractor GREEN CIRCLE CONSTRUCTION INC Date 08/31/2019 YX BLDG—ELECT—PLUMB [hereby affirm that I am licensed under the provisions of Chapter 9(commencing X 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: BATHROOM REMODEL(432 S.F.);CONSTRUCT(N)WALK 1N I hereby affirm under penalty of perjury one of the following two declarations: CLOSET AND REMODEL LAUNDRY CLOSET(103 S.F.) r. I have and will maintain a certificate of consent to self-insure for Worker's REV#1 REPLACE FURNACE-SAME LOCATION-ISSUED JJJ,Compensation,as provided for by Section 3700 of the Labor Code,for the 06/14/2018 performance of the work for which this permit is issued. - have and will maintain ce Worker's Compensation Insuran ,as provided far by Section 3700 ofthe Labor Code,for the performance of the work for which this permit is issued. Sq.Ft Floor Area: Valuation:$53200.00 APPLICANT INTiFICATION 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 slate laws relating to building construction,and hereby authorize 356 28 037 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 WORT{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 Municipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION. Signature Date Issued by:AbbyAAyendc Date:01/04/2018 OWNER—OWNER-111 R I hereby affirm that I am exempt from the Contractor's License Law for one of the RE-ROOTS: following two reasons: All roofs shall be inspected prior to any roofing material being installed.If a roof is r. 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(Sce.7044,Business&Professions Code) z I,as owner of the property,am exclusively contracting with licensed Signature of Applicant: contractors to construct the project(Sce.7044,Business&Professions Code). Date: I hereby affirm under penalty orperjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER1. 1 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 z I have and will maintain Worker's Compensation Insurance,as provided for by I have read the 1—rdous materials requirements under Chapter 6.95 or the Section 3700 of the Labor Code,for the performance of the work for which this California Health&Safety Code,Sections 25505,25533,and 25534.1 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,1 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 hnzardous air contaminants i s defined by the Bay Area Air Quality Management District 1 Worker's Compensation laws of Califoornia,H,aRer making this certificate of will maintain compliance with the Cupertino Municipal Cade,Chapter 9.12 and exemption,l 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 be deemed revoked. Owner or authorized agent: APPLICANT CERTIFICATION Date: I certify that I have read this application and state that the above Information is CON9r'1'RI) correct.I agree to comply with all city and county ordinances and state laws I hereby affirm the ere 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. 1 understand my plans shall be used as public records. Licensed Signature Date Professional CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2017-2187 11032 CANYON VISTA DR CUPERTINO,CA 95014-5405(356 28 037) GREEN CIRCLE CONSTRUCTION INC BERKELEY,CA 94705 OWNER'SNAME: DA'Z'E ISSUED;01/04/2018 OWNER'S PHONE: PHONE NO:( LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: License Class B Lie.4936581 . Contractor GREEN CIRCLE CONSTRUCTION INC Date 08131/2019 X BLDG ELECT—PLUMB I hereby affirm that I am licensed under the provisions of Chapter 9(commencing X MECH X RESIDENTIAL_COMMERCIAL with Section 7000)of Division 3 of the Business&Professions Code and that my license is in fall force and effect. JOB DESCRIPTION: BATHROOM REMODEL(432 ST);CONSTRUCT(N)WALK IN 1 hereby affirm under penalty of perjury one ofthe follmving I've declarations: CLOSETAND REMODEL LAUNDRY CLOSET(103 S.F.) r. I have and will maintain a certificate of consent to self-insure for Worker's REV#l REPLACE FURNACE-SAME LOCATION-ISSUED Compensation,as provided for by Section 3700 of the Labor Code,for the 06/14/2018 perromraone of the work for which this permit is issued. REV#2-REVISED MASTER BATHROOM REMOVE TUB WITH I have and will maintain Worker's Compensation Insurance,as provided for by ENLARGED SHOWER;RELOCATE BEDROOM(1)ENTRY DOOR; Section 3700 of the Labor Code,for the performance of the work(m which this ELIMINATE EXISTING FIREPLACE BY SHEET-ROCKING AND permit is issued. CAPPING OFF THE CHIMNEY VENT TERMINATION;IN LIVING APPLICANT CERTIFICATION ROOM/HALLWAY ADD(2)SETS OF TRACK LIGHTS, ISSUED 7-20- 1 certify that I have read this application and state that the above 2018 Information is correct.I agree to comply with all city and county ordinances Sq,Ft Floor Area: Valuation:$53200.00 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 pPN Number: Occupancy Type: City of Cupertino against liabilities,judgments,costs,and expenses which 356 28 037 may accrue against said City in consequence of the granting of this permit. Additionally,the applicant understands and willcomply with all non-point source regulations pe�Ct ieil5al Code,Section 9.18. PERMIT EXPIRES IF WORK IS NOT STARTED Signature Date 7-20-2018 WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTION. OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the ContractmPs License Law fmone of the Issued by:Abby Ayende following two reasons: Date:01/04/2018 r. 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 RE-ROOFS: sale(Sec.7044,Business&Professions Code) All roofs shall be inspected prior to any roofing material being installed.If e roof is 2. I,as owner of the property,am exclusively contracting with licensed installed without first obtaining an inspection,1 agree to remove all new materials for contractors to constmet the project(Sec.7044,Business&Professions Cade). inspection, I hereby affirm tinder penalty of perjury one of the following three declarations: r. I have and will maintain a Certificate of Consent to self-insure for Worker's Signature of Applicant: Compensation,as provided for by Section 3700 of the Labor Code,for the Data:7-20-2018 performance of the work for which this permit is issued. 2. I have and will maintain Worker's Compensation Insurance,as provided for by ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. HAZARDOUS MATERIALS DISCLOSURE s. I certify that in the performance of the work for which this permit is issued,I I have read the hazardous materials requirements under Chapter 6.95 of the shall not employ any person in any manner so as to become subject to the California Health&Safety Code,Sections 25505,25533,and 25534.f will Worker's Compensation laws of California.If,after making this certificate ofnr inlain compliance with the Cupertino Municipal Cuda,Chapter 9.12 and the exemption,l become subject to the Worker's Compensation provisions of the Health&Safety Code,Section 25532(x)should I store or handle hazardous Labor Code,I must forthwith comply with such provisions or this permit shall material.Additionally,should I use equipment or devices which emit hazardous be deemed revoked 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 APPLICANT CERTIFICATION the Health&Safety Code,Sections 25505,25533,and 25534, 1 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 a or Owner authorized agent: ,., relating to building construction,and hereby authorize representatives of this city Date:r or 018 to enter upon the above mentioned property for inspection purposes. (We)agree CONSTRUCTION LENDING AGENCY to save indemnify and keep harmless the City of Cupertino against liabilities, I hereby affirm that there T a construction lending agency for the performance judgments,costs,and expenses which may accrue against said City in of work's for which this permit is issued(Sec.ding a Civ C.) consequence of the granting of this permit.Additionally,the applicant understands Lender's Name .and will comply with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. Lender's Address Signature Date 7-20-2018 ARCHITECT'S DECLARATION I understand my plans shall be used as public records.