B-2017-0515`. CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2017-0515
10718 NATHANSON AVE CUPERTINO,CA 95014-1332(326 43 070) HOMEOWNER
BUILDER
OWNER'S NAME: Reyes Vito O And Rebecca D Et AI DATE ISSUED:01/22/2018
OWNER'S PHONE: PHONE NO:
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class Lic.#
Contractor HOMEOWNER BUILDER Date X BLDG —ELECT X 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 full force and effect. JOB DESCRIPTION:
INTERIOR REMODEL OF MAIN RESIDENCE(1674 SF);KITCHEN
I hereby affirm under penalty of perjury one of the following two declarations: ADDITION(141 SF);BEDROOM#7 ADDITION(93 SQ FT);CONVERT
t. I have and will maintain a certificate of consent to self-insure for Worker's PATIO TO BEDROOM#2(304 SF);CONSTRUCT(N)COVERED SUN
Compensation,as provided for by Section 3700 of the Labor Code,for the ROOM(120 SF);INSTALL(N)FURNACE AND WATER HEATER;
performance of the work for which this permit is issued. DEMOLISH IN-GROUND SWIMMING POOL;DEMOLISH ILLEGAL
2. I have and will maintain Worker's Compensation Insurance,as provided for by ACCESSORY STRUCTURE BUILT AT POOL LOCATION;DEMOLISH
Section 3700 of the Labor Code,for the performance of the work for which this SHEDS AT REAR OF PROPERTY.
permit is issued. REV#2-FRAMING DETAIL DINING,LIVING,FOYER AREAS,
APPLICANT CERTIFICATION BEDRM#1 LAYOUT CHANGE;CONVERT(E)SKYLIGHT TO(2)
1 certify that I have read this application and state that the above SKYLIGHTS-11 10-0-04- °1140 18
information is correct.I agree to comply with all city and county ordinances REV#1-MOVED FOUNDATION-ISSUED 03-05-2018
and state laws relating to building construction,and hereby authorize
representatives of this city to enter upon the above mentioned property for Sq.Ft Floor Area: Valuation:$100000.00
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. APN Number: Occupancy Type:
Additionally,the applicant understands and will comply with all non-point 32643 070 R-3(Custom)
source regulations per the Cupertino Municipal Code,Section 9.18.
PERMIT EXPIRES IF WORK IS NOT STARTED
Signature Date o9/10/2018 WITHIN 180 DAYS OF PERMIT ISSUANCE OR
OWNER-BUILDER DECLARATION 180 DAYS FROM LAST CALLED INSPECTION.
I hereby affirm that 1 am exempt from the Contractor's License Law for one of the
folloC two reasons: Issued by:Jasmine Archbold
t. I,as owner of the property,or my employees with wages as their sole Date:01/22/2018
compensation,will do the work,and the structure is not intended or offered for
sale(Sec.7044,Business&Professions Code) RE-ROOFS:
z. I,as owner of the property,am exclusively contracting with licensed All roofs shall be inspected prior to any roofing material being installed.If a roof is
contractors to construct the project(Sec.7044,Business&Professions Code). installed without first obtaining an inspection,I agree to remove all new materials for
I hereby affirm under penalty of perjury one of the following three declarations:
inspection.
�. 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 Signature of Applicant:
performance of the work for which this permit is issued. Date:09/10/2018
2. 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 ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
permit is issued.
3. I certify that in the performance of the work for which this permit is issued,I HAZARDOUS MATERIALS DISCLOSURE
shall not employ any person in any manner so as to become subject to the I have read the hazardous materials requirements under Chapter 6.95 of the
Worker's Compensation laws of California. If,after making this certificate of California Health&Safety Code,Sections 25505,25533,and 25534. I will
exemption,I become subject to the Worker's Compensation provisions of the maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
Labor Code,I must forthwith comply with such provisions or this permit shall Health&Safety Code,Section 25532(a)should I store or handle hazardous
be deemed revoked. material. Additionally,should I use equipment or devices which emit hazardous
air contaminants as defined by the Bay Area Air Quality Management District I
APPLICANT CERTIFICATION will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and
I certify that I have read this application and state that the above information is the Health&Safet tions 25505,25533,and 25534.
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 Owner or authorized agent:
to save indemnify and keep harmless the City of Cupertino against liabilities, Date:09/10/2018
judgments,costs,and expenses which may accrue against said City in CONSTRUCTION LE DING A -�
consequence of the granting of this permit. Additionally,the applicant understands I hereby affirm that there is a construction lending gency for the performance
and will comply with alj-non-point source regulations per the Cupertino Municipal of work's for which this permit is issued(Sec.3097,Civ C.)
Code,Section 9A Lender's Name
Lender's Address
Signature Date 09/10/2018
ARCHITECT'S DECLARATION
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2017-0515
10718 NATHANSON AVE CUPERTINO,CA 95014-1332(326 43 070)
OWNER'S NAME: Reyes Vito 0 And Rebecca D Et Al DATE ISSUED:01/22/2018
OWNER'S PHONE: PHONE NO:
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class Lic.#
Contractor Date X BLDG _ELECT X 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 full force and effect. JOB DESCRIPTION:
INTERIOR REMODEL OF MAIN RESIDENCE(1674 SF);KITCHEN
I hereby affirm under penalty of perjury one of the following two declarations: ADDITION(141 SF);BEDROOM#7 ADDITION(93 SQ FT);CONVERT
/, t, I have and will maintain a certificate of consent to self-insure for Worker's PATIO TO BEDROOM#2(304 SF);CONSTRUCT(N)COVERED SUN
Kf` Compensation,as provided for by Section 3700 of the Labor Code,for the ROOM(120 SF);INSTALL(I)FURNACE AND WATER HEATER;
performance of the work for which this permit is issued. DEMOLISH IN-GROUND SWIMMING POOL;DEMOLISH ILLEGAL
z. I have and will maintain Worker's Compensation Insurance,as provided for by ACCESSORY STRUCTURE BUILT AT POOL LOCATION;DEMOLISH
Section 3700 of the Labor Code,for the performance of the work for which this SHEDS AT REAR OF PROPERTY.
permit is issued. REV#3-CHANGE CEILING JOIST DIMENSION-ISSUED 9/12/18
APPLICANT CERTIFICATION REV#2-FRAMING DETAIL DINING,LIVING,FOYER AREAS,
I certify that I have read this application and state that the above BEDRM#1 LAYOUT CHANGE;CONVERT(E)SKYLIGHT TO(2)
information is correct.I agree to comply with all city and county ordinances SKYLIGHTS-ISSUED 9-10-2018
and state laws relating to building construction,and hereby authorize REV#1-MOVED FOUNDATION-ISSUED 03-05-2018
representatives of this city to enter upon the above mentioned property for
inspection purposes. (We)agree to save indemnify and keep harmless the Sq.Ft Floor Area: Valuation:$100000.00
City of Cupertino against liabilities,judgments,costs,and expenses which
may accrue against said City in consequence of the granting of this permit.
Additionally,thea nt understands and will comply with all non-point APN Number: Occupancy Type:
source regula' er the Cupertino Municipal Code,Section 9.18. 32643070 R-3(Custom)
Signature Date 09/12/18 PERMIT EXPIRES IF WORK IS NOT STARTED
OWNER-BUILDER DECLARAT N WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
I hereby affirm that I am exempt o he Contractor's License Law for one of the
following two reasons:
m. I,as owner of the property,or my employees with wages as their sole Issued by:Jasmine Archbold
compensation,will do the work,and the structure is not intended or offered for Date:01/22/2018
sale(Sec.7044,Business&Professions Code)
I,as owner of the property,am exclusively contracting with licensed RE-ROOFS:
contractors to construct the project(Sec.7044,Business&Professions Code). All roofs shall be inspected prior to any roofing material being installed.If a roof is
I hereby affirm under penalty of perjury one of the following three declarations: installed without fust obtaining an inspection,I agree to remove all new materials for
m. 1 have and will maintain a Certificate of Consent to self-insure for Worker's inspection.
Compensation,as provided for by Section 3700 of the Labor Code,for the
performance of the work for which this permit is issued. Signature of Applicant:
2. I have and will maintain Worker's Compensation Insurance,as provided for by Date:09/12/18
Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued. ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
V3. 1 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 HAZARDOUS MATERIALS DISCLOSURE
Worker's Compensation laws of California. If,after making this certificate of I have read the hazardous materials requirements under Chapter 6.95 of the
exemption,I become subject to the Worker's Compensation provisions of the California Health&Safety Code,Sections 25505,25533,and 25534. I will
Labor Code,I must forthwith comply with such provisions or this permit shall maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
be deemed revoked. Health&Safety Code,Section 25532(a)should I store or handle hazardous
material. Additionally,should I use equipment or devices which emit hazardous
APPLICANT CERTIFICATION air contaminants as defined bythe Bay Quality Management District I
I certify that I have read this application and state that the above information is will maintain compliance with the ino Municipal Code,Chapter 9.12 and
correct.I agree to comply with all city and county ordinances and state laws the Health&Safety ,Sectio 25505,2553 34.
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, Owner or authorized agent:
judgments,costs,and expenses which may accrue against said City in Date:09/12/18
consequence of the granting of this permit. Additionally,the applicant understands CONSTRUCTION LENDING AGENCY
and will comply with n-point source regulations per the Cupertino Municipal I hereby affirm that there is a construction lending agency for the performance
Code,Section 9 of work's for which this permi ed(Sec.3097,Civ C.)
Lender's Name
Signature Date9/0 12/18 Lender's Addr s
ARCHITECT'S DECLARATION