B-2018-0255 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:13-2018-0255
20318 CLAY ST CUPERTINO,CA 95014-4401(369 39 018) SUCCESSFUL
CONSTRUCTION INC
FREMONT,CA 94538 '
OWNER'S NAME: DATE ISSUED:04/25/2018
OWNER'S PHONE: PHONE NO:(
LICENSED CON'TRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class GENERAL BUILDING CONTRACTOR Lia,#9913612
Contractor SUCCESSFUL CONSTRUCTION INC Date 07/31/2020 X BLDG X ELECT—PLUMB
I herebyform that I am licensed under the provisions of Chapter 9(commencing —MECH X RESIDENTIAL_COMMERCIAL
a P F (cam g
with Section 7000)of Division 3 of the Business&Professions Code and that my
license is in full farce and effect. JOB DESCRIPTION:
ADDITION TO LIVING ROOM,2 BEDROOMS AND BATHROOMS
I hereby affirm under penalty of perjury one of the following two declarations: (677 S.F);INSTALL SUN TUNNELS(7);REMOVE WALL BETWEEN
t. I have and will maintain a certificate of consent to self-insure for Worker's KITCHEN AND DINING ROOM
Compensation,as provided for by Section 3700 of the Labor Code,for the REV 91-KITCHEN REMODEL(201 S.F.)-ISSUED 05-21-2018
)/„performance of the work for which this permit is issued. REV 92-ADD TRAY CEILING TO FAMILY ROOM-ISSUED 7/11/2018
have and will maintain Worker's Compensation Insurance,as provided for by REV#3-ADD SUB-PANEL IN PANTRY-(70 AMP)-ISSUED
Section 3700 of the Labor Code,for the performance of the work for which this 08/20/2018
Permit is issued. Sq.Ft Floor Aren:677 Vnluadon:$151000.00
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above
information Is correct.I agree to comply with all city and county ordinances APN Number: Occupancy Type:
and state laws relating to building construction,and hereby authorize 369 39 018 R-3(Custom)
representatives of this city to enter upon the above mentioned property for
Inspection purposes. (We)agree to save indemnify and keep harmless the
City of Cupertino against liabilities,judgments,costs,and expenses which PERMIT EXPIRES IF WORK IS NOT STARTED
may accrue against said City in consequence of the granting of this permit.
Additionally,the applicant understands and will comply with all non-point WITHIN 180 DAYS OF PERMIT ISSUANCE OR
source regulations�per theCupertinoMunicipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
Signature Date$I�`I$
—� � Issued 0y:Jasmitic Archbold
Date:04/25/2018
OWNER-BUILDER DECLARATION
I hereby offirm that I am exempt from the Contractor's'License Law for one or theRE-ROOFS:
following two reasmmo All roofs shall be inspected prior to any roofing material being installed.If a roof is
t. 1,as owner ofthe property,or my employees with wages as their sole installed without first obtaining an inspection,I agree to remove all new materials fur
compensation,will do the work,and the structure is not intended or offered for inspection,
sale(Sec.7044,Business&Professions Cade)
z. I,as owner o£the property,am exclusively contracting with licensed Signature of Applicant:
contractors to construct the project(Sec.7044,Business&Professions Code). Data
1 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 ALI,ROOF COVERINGS TO BE CLASS"A"OR BETTER
Compensation,as provided for by Section 3700 of lire 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 hazardous materials requirements under Chapter 6.95 of the
Section 3700 of the Lubar Cade,for line 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
a. I certify that in the performance of the work I'or which this permit is issued,I Health&Safety Cade,Section 25532(x)should I store or handle hazardous,
shall not employ any person in any manner so as to became subject to the material.Additionally,should I use equipment or devices which emit hazardous
Worker's Compensation laws of California.If,after making this certificate of aIr cnamed.ants as defined by the Buy Area Air Quality Management District 1
exemption,I become subject to the Worker's Compensation provisions of the will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and
Labor Code,1 must forthwith comply with such provisions or this permit shall the Health&Safety Cade,pSections 25505,25533,and 25534.
be deemed revoked
Owner or authorized agent:
APPLICANT GEIITI III Data:
I certify that I have read this application and stale that the above information is 2O�(C NSTRl1CT10N LENDING AGENCY
correct.I agree to comply with all city and county ordinances and state laws I hereby affirm t at 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 ARCHIT'ECT'S DECLARATION
Code,Section 9.18. 1 understand my plans shall be used as public records.
Signature Date Licensed
Professional
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2018-0255
20318 CLAY ST CUPERTINO,CA 95014-4401(369 39 018) SUCCESSFUL
CONSTRUCTION INC
FREMONT,CA 94538
OWNER'S NAME: DATE ISSUED:04/25/2018
OWNER'S PHONE: PHONE NO:(
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class B Lic.#913812
Contractor SUCCESSFUL CONSTRUCTION INC Date 07/31L2018 X BLDG ELECT_PLUMB
I hereby affirm that 1 nm licensed under the provisions of Chapter 9(commencing MECH X RESIDENTIAL_COMMERCIAL
with Section 7000)o£Division 3 of the Business&Professions Code and that my
license is 1n fall force and effect. JOB DESCRIPTION:
ADDITION TO LIVING ROOM,2 BEDROOMS AND BATHROOMS
I hereby affirm under penalty of perjury one of the following two declarations: (677 ST);INSTALL SUN TUNNELS(7);REMOVE WALL BETWEEN
i. 1 have and will maintain a certificate of cmvsent to self-insure for Worker's KITCHEN AND DINING ROOM
Compensation,as provided for by Section 3700 of the Labor Code,for the REV#I-KITCHEN REMODEL(201 S.F.)-ISSUED 05-21-2018
\ etion 3700 of the Labor Code,for the performance of the work for which this
permit is issued'r./' Sq.Ft Floor Area:677 Valuation$150000.00
P ICANT CERTIFICATION
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 APN Number: Occupancy Type:
and slate laws relating to building construction,and hereby authorize 369 39 018 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 WORI{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 05-21-2018 Issued by:Jasmine Archbold
Date:04/25/2018
OWNL'R-BUILD�R DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law far one of(]is RE-ROOFS:
following two reasans: All roofs shall be inspected prior to any roofing material being installed.If.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 far
compensation,will do the work,and the structure is not intended or offered for inspection.
sale(See.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). Datc:05-21-2018
1 hereby affirm under penalty of'perjury one of the following three declarations: ALLROOF COVERINGS TO BE CLASS"A"OR BETTERr. 1 have and will maintain a Certificate of Consent to self'-home 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 requh em nits 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 Cade,Section 25532(x)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 25534.
Labor Code,I must forthwith comply with such provisions or this permit shall
be deemed revoked, Owner or authorized agent:
APPLICANT CERTIFICATION Date:05-21-2018
1 certify that I have read this application and slate that the above information is CONSTRUCTI 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. 1 understand my plans shall be used as public records.
Signature Date 05-21-2018 Licensed
Professional
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2018-0255
20318 CLAY ST CUPERTINO,CA 95014-4401(369 39 018) SUCCESSFUL
CONSTRUCTION INC
FREMONT,CA 94538
OWNER'S NAME: DATE ISSUED:04/25/2018
OWNER'S PHONE: PHONE NO:(
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class B Llc,#2136J2
Contractor SUCCESSFUL CONSTRUCTION INC Date 07/31/2018 X BLDG ELECT_PLUMB
I herebyaffirm that I am licensed under the provisions of Chapter 9 —MECH X RESIDENTIAL_COMMERCIAL
p p (commencing
with Section 7000)of Division 3 of the Business&Professions Cade and that my
license is in full force unit effect. JOB DESCRIPTION:
ADDITION TO LIVING ROOM,2 BEDROOMS AND BATHROOMS
I hereby affirm under penalty of perjury one of tare following two declarations: (677 ST);INSTALL SUN TUNNELS(7);REMOVE WALL BETWEEN
r. I have and will maintain a certificate of consent to self-insure for Worker's KITCHEN AND DINING ROOM
Compensation,as provided for by Section 3700 of the Labor Code,for the REV 91-KITCHEN REMODEL(201 S.F.)-ISSUED 05-21-2018
performance of the work for which this permit is issued. REV#2-ADD TRAY CEILING TO FAMILY ROOM-ISSUED 7/11/2018
ave 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. Sq.Ft Floor Area:677 Valuation:$150000.00
APPLICANT CERTIFICATION
I certify that I have read this application and slate 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 39 018 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
source regulations per the Cupertino Municipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
Signature Date 7/11/2018 Issued by:Jasmine Archbold
Date:04/25/2018
OWNER-BUI ER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of the RE-ROOFS,
following aro reasons: All roofs shall be inspected prior to any roofing motorial being installed If a roof is
t. I,as owner of the properly,or my employees with wages as their sole Installed without first obtaining an inspection,I agree[o remove all now mMtedid.,for
compensation,will do the work,and the structure is not intended or offered for inspection.
,at.(Sec.7044,Business&Professions Code)
4 I,as owner of the property,am exclusively contracting with licensed Signature of Applicant:
contractors to construct the project(Sec,7044,Business&Professions Cade), -bate;`/I/ I�1�
I hereby affirm under penalty of perjury•one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
r. 1 have and will maintain a Certificate of Consent to self-insure foo Worker's
Compensation,as provided for by Section 3700 of the Labor Code,for the
performance ofthe work for which this permit is issued. HAZARDOUS MATERIALS DISCLOSURE
z. 1 have and will maintain Worker's Compensation Insurance,as provided fon by I have read the h—rhius nmterials requirements order Chapter 6.95 of the
Section 3700 c f the Labor Code,Y'or[he 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,Chaptm 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 1 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 Are.At.-Quality Men ismer t District I
Worker's Compensation laws of California.If,after making this certificate of will maintain cmnpliance with the Cupertino Municipal Cade,Chapter,9.12 and
emption,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
be deemed revoked, Owner or authorized agent:
APP'LICAN'T CERTIFICATION Date: 11
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 ARCHyrECT'S DECLARATION
Code,Section 9.18. 1 understand my plans shall be used as public records.
Licensed
Signature Date ZLI112018
Professional