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B-2018-0679 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2018-0679 22791 STONEBRIDGE ST CUPERTINO,CA 95014-5638(342 13 045) XANADU CONSTRUCTION INC SARATOGA,CA 95070 OWNER'S NAME: DATE ISSUED:04/25/2018 OWNER'S PHONE: PHONE NO:(408)892-8402 LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: License Class B Lic.#949373 Contractor XANADU CONSTRUCTION INC Date 06/30/2020 X BLDG X 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 full force and effect. JOB DESCRIPTION: REMODEL(2)BATHROOM(200 SF);REMODEL OTHER(178 SF); I hereby affirm under penalty of perjury one of the following two declarations: INSTALL(24)RECESSED LIGHTS THROUGH-OUT HOUSE 1. I have and will maintain a certificate of consent to self-insure for Worker's REV#1-KITCHEN REMODEL(227 SF);REPLACE DOORS& Compensation,as provided for by Section 3700 of the Labor Code,for the WINDOWS(12 )-ISSUED 8/22/18 performance of the work for which this permit is issued. REV#2 ADD A WALL IN MASTER TO CREATE CLOSET-(85 SF)- 2. I have and will maintain Worker's Compensation Insurance,as provided for by ISSUED 11/06/2018 Section 3700 of the Labor Code,for the performance of the work for which this REV#3-INSTALL(N)SPLIT SYSTEM-ISSUED 3/18/19 permit is issued. APPLICANT CERTIFICATION Sq.Ft Floor Area: Valuation:$90000.00 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 state laws relating to building construction,and hereby authorize 342 13 045 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 reg lations per the Cupertino Municipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION. Signature Date 3/18/19 Issued by:Jasmine Archbold Date:04/25/2018 OWNER-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:3/18/19 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 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 3. 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 Worker's Compensation laws of California. If,after making this certificate of air contaminants as defined by the Bay Area Air Quality Management District I 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,I must forthwith comply with such provisions or this permit shall the Health&Safety Code ections 25505,25533,and 25534. be deemed revoked. Owner or authorized agent: APPLICANT CERTIFICATION Date:3/18/19 1 certify that I have read this application and state that the above information is CONSTRUCTION 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 3/18/19 Licensed Professional CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: CONTRACTOR: PERMIT NO: B-2018-0679 22791 STONEBRIDGE ST CUPERTINO, CA 95014-5638 (342 13 045) XANADU CONSTRUCTION INC SARATOGA, CA 95070 OWNER'S NAME: DATE ISSUED: 04/25/2018 OWNER'S PHONE: PHONE NO: (408) 892-8402 LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: License Class B Lic. #949373 Contractor XANADU CONSTRUCTION INC Date 06/30/2020 X BLDG X ELECT _ PLUMB MECH X RESIDENTIAL _ COMMERCIAL 1 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. JOB DESCRIPTION: REMODEL (2) BATHROOM ( 200 SF); REMODEL OTHER (178 SF); I hereby affirm under penalty of perjury one of the following two declarations: INSTALL (24) RECESSED LIGHTS THROUGH-OUT HOUSE 1. I have and will maintain a certificate of consent to self-insure for Worker's REV#1 - KITCHEN REMODEL (227 SF); REPLACE DOORS & Compensation, as provided for by Section 3700 of the Labor Code, for the WINDOWS (12 ) - ISSUED 8/22/18 performance of the work for which this permit is issued. REV # 2 ADD .A WALL IN MASTER TO CREATE CLOSET - (85 SF) - I have and will maintain Worker's Compensation Insurance, as provided for by ISSUED 11%06/2018 Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. Sq. Ft Floor Area: Valuation: $90000.00 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 Number: Occupancy Type: 342 and state laws relating to building construction, and hereby authorize 342 13 045 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 ®F 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 11/06/2018 Issued by: Jasmine Archbold Date: 04/25/2018 OWNER-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: 11/06/2018 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 3. 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 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 & Safety Code -,S etions 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: 11/06/2018 certify that I have read this application and state that the above information is CONSTRUCTION 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. Licensed Signature Date 11/06/2018 Professional CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: - CONTRACTOR: PERMIT NO:B-2018-0679 22791 STONEBRIDGE ST CUPERTINO,CA 95014-5638(342 13 045) XANADU CONSTRUCTION INC SARATOGA,CA 95070 OWNER'S NAME: DATE ISSUED:04/25/2018 OWNER'S PHONE: PHONE NO:( LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: License Class 13 Lic.49 3 3 Contractor XANADU CONSTRUCTION INC Date 06/30/2020 X BLDG x ELECT_PLUMB I hereby affirm that I am licensed under the provisions of Chapter 9(commencing —MECR X RESIDENTIAL_COMMERCIAL with Section 7000)of Division 3 of the Business&Professions Code and that my geense is In fug farce mid effect. JOB DESCRIPTION: REMODEL(2)BATHROOM(200 SF);REMODEL OTHER(178 SF); - I-hereby affirm under penalty of perjury one of the following two declarations: INSTALL(24)RECESSED LIGHTS THROUGH-OUT HOUSE' 1. 1 have and will maintain a certificate of consent to self-insure for Worker's REV41-KITCHEN REMODEL(227 SF);REPLACE DOORS& Compensation,as provided for by Section 3700 of the Labor Code,for the WINDOWS(12)-ISSUED 8/22/18 performance of the work for which this permit is issued. - I have and will maintain Worker's Compensation Insurance,as provided for by is issued. Sq.Ft Floor Area: Valuation:$90000,00 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 34213 045 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 08/22/18 Issued by:Jasmine Archbold - Data:04/25/2018 �`FR-BIRi DER DECLARATION I Hereby affirm that I am exempt from the Contractor's License Law for one of the RE-ROOES; 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 thew 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,ace exclusively contracting with licensed Signature ofApplicant contractors to construct the project(Sec.7044,Business&Professions Code). Date:08/22/18 I hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER r. I have mid will maintain a Certificate ofConsent 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 and 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 Cagfonda 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 I I certify that in the performance of the work for which Us permit is issued,I Health&Safety Code,Section 25532(a)should I store or handle Hazardous shall not employ anyperaon in any rummer so as to became 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 cenificato 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:44/22/]$ I certify that I have read this application and state that the above Information Is CO correct.I agree to comply with all city and county ordinances and state laws I hereby affirm that there is a construction lending agen6y 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 AR HIT T'S DE ARATION Code,Section 9.18. 1 understand my plans shall be used as public records. Signature Data 08/22/18 Licensed Professional