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B-2017-1931 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2017-1931 10271 MENHART LN CUPERTINO,CA 95014-3629(375 15 028) K&M DEVELOPMENTINC CUPERTINO,CA 95014 OWNER'S NAME: DATE ISSUED:04/30/2019 OWNER'S PHONE: PHONE NO:(408)390.5127 LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: License Class 3 Lia#Z4L814 Contractor K&M DEVELOPMENT INC Date 10/31/2019 X BLDG_ELECT_PLUMB 1 herebyform that I am licensed under the visions of Cha ter 9 _MECH X RESIDENTIAL_COMMERCIAL a pro p (commencing with Section 7000)of Division 3 of the Business&Professions Code and that my license is in full force and effect JOB DESCRIPTION: CONSTRUCT(N)SINGLE STORY SFD(1907 S.F.);ATTACHED I hereby affirm under penalty of perjury one of the following two declarations: GARAGE(446 S.F,);FRONT PORCH(24 S.F,);ATTACHED 2ND UNIT r. I have and will maintain a certificate of consent to self-insure fou Worker's (346 S.F.) Compensation,as provided for by Section 3700 of the Labor Code,for the REV#I-UPDATE DAMPER PER UL U555 IN SHEET EMI-ISSUED performance of the work for which this permit is issued. 06/11/2018 1 have and will maintain Worker's Compensation Insurance,as provided far by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued, Sq.Ft Floor Area:2253 Valuation;$550000,00 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 375 15 028 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. Signatur _— Date 06/11/2018 Issued by:Kim Dunbar Date:04/30/2018 OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for one of the RE-ROOFS: ]'allowing two reasons: All roofs shall be inspected prior to any roofing material being installed.If's roof is 1. I,as owner of the property,or my employees with wages as their sole installed without first obtaining an inspection,1 agree to remove all new materials for compensation,will do the work,and the structure is not intended at offered far inspection. sale(Sec.7044,Business&Professions Code) z I,a owner of the property,am exclusively contracting with licensed Signature of Applicane contractors to construct the project(Sec.7044,Business&Professions Code). Date:06/11/2018 I hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER 1. 1 have and will maintain a Certificate of Consent to self-insure£or 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. 1 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 s. 1 certify that in the performance of the work for which this permit is issued,I Health&Safety Code,Section 25532(.)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 ager APPLICANT CERTIFICATION Date:06/11/2018 I 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 Clty 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 ABCH1'1'ECT S DECLARATION Code,Section 9.18. 1 understand my plans shall be used as public records. Signature Date 06/11/2018 Licensed Professional NO FEE FOR RECORDING PURSUANT TO GOVERNMENT CODE SECTION 27383 When Recorded MaH To: City of Cupertino Community Development Department 10300 Torre Avenue Cupertino, CA 95014 Regina Abcomendras Santa Clara County - Clerk -Recorder 03/22/2019 10:33 AM Titles: 1 Pages: 3 Fees: 0.00 Taxes: 0 Total: 10.00 III NOTICE p d � CITY REQUIREMENT 3 9 s �u i �i is I 7 �, 9 �.� '1 !' d� u C TED i E 1.' e, O a- L 5, The undersigned, being the owner(s) of the property shown in the Santa Clara County Assessor's Roll land 'identified as A.P.N. 375-15-028 and addressed as 10271 Menhart Lane, hereby agree(s) that the approved landscape shall be maintained and consistent to the approved plan in conjunction with Building Permit no. B-2017-1931 and,Planning Permit no. RM -2017-29, and shall be in conformance with the City's Landscape Ordinance. The applicant may consult the,City of Cupertino's Planning Department prior to any modifications to the landscape; however, any proposed" tlsree rem shall require approval by the City of Cupertino. Changes to the plan may be made under the following conditions: 1. Plants that have water usage requirements consistent with the City's Landscape Ordinance as determined by the ` Water Use Classifications of Landscape Species manual; or 2. Plants that are low-water using, native to California and appropriate for use in the area by the Santa Clara Valley Water District, Santa Clara Valley Chapter of the California Native Plant Society, the Master Growers Santa Clara County, or a certified Landscape Architect or ISA certified Arborist or 3. Preparation of new landscape and irrigation plans in conformance with Chapter 14.1.5 (Landscape Ordinance) } C�LlF�F'���I/�; 1LL hUR�=O�� F1C��I,�OO1'JLEDDG��IEf`1T CIVIL CODE § 11$9 A notary public or other officer completing this certificate verifies only the identity of the individual who signed the document to which this certificate is attached, and not the truthfulness, accuracy, or validity of that document. State of California County of Sante CI CAS On M0KY) 22"'Dr 20 19 before me, :�11P_1 muA. w M . W 0-h�Vu Pu bk t c , Date Here Insert Wame and TiK le of the Officer personally appearedyang and Kee Yam Dim Name(s) of Signer(s) who proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies),`and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument. I certify under PENALTY OF PERJURY under the ELLEN Mu�sEa� laws of the State of California that the foregoing e NotariPublic- California SamiraCounty Commission 4 2229737 z paragraph is true and correct. My Comm. Expires Jan 28, 2022 - WITNESS my hand and official seal. Signature 6& NJ-fZZ,-Q Place Notary Seal and/or Stamp Above Signature of Nota ublic �Ir a aON] LL. Completing this information can deter alteration of the document or fraudulent reattachment of this form to an unintended document. Description of Attached Document Title or Type of Document:N 6f CQ PeaLAAC'.UViP� * vnaa n� 0q cA� (� Document Date: ph In 120Number of Pages: Q Signer(s) Other Than Named Above: j -S *A�ro�a� pool ® -jjre Capacity(les) Claimed by Signer(s) Signer's Name: Kel �A Van!51l ❑ Corporate Officer - Title(s): [],,Partner - ❑ Limited ❑ General 9 Individual ❑ Attorney in Fact ❑ Trustee ❑ Guardian of Conservator ❑ Other: Signer is Representing: 02017 National Notary Association Signer's Name: Kew Y 0LMC+Z) ❑ Corporate Officer - Title(s) [],Partner - ❑ Limited o General E Individual ❑ Attorney in Fact El Trustee ❑ Guardian of Conservator ❑ Other: Signer is Representing: cape IO ;t A ALL-PURPOSE CERTIFICATE a RfiA] ^, ACKNOWLEDGMENT .yM A notary public or other officer completing this certificate verifies only the identity of the individual who signed the document to which this certificate is attached, and not the truthfulness, accuracy, or validity of that document. State of California County of Clara On All 2( ,?toky before me, ffr;-s- i e �.t ���a r e�`g , Notary Public, (Here insert name and title of the officer) personally appeared (57 who proved to on the basis of satisfactory evidence to be the personWwhose name,(g is/are subscribed to the within instrument and acknowledged to me thatshe/they executed the same inis/her/their authorized capacity(i4, and that by leis/her/their signatureW on the instrument the person, or the entity upon behalf of which the personV acted, executed the instrument. I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and correct. WITNESS my hand and official seal. Signature of Notary Public KIRSTEN S,QUARCI& Wp Notary Public • California Z Santa Clara County Y Commission !# 2257322 �9[IF00.H My Comm. Expires Oct 4, 2022 (Notary Seal) ADDITIONAI., OPTION. INFORMATION DESCRIPTION OF THE ATTACHED DOCUMENT (Title or description of attached document) (Title or description of attached document continued) Number of Pages Document Date (Additional information) CAPACITY CLAIMED BY THE SIGNER ❑ Individual (s) ❑ Corporate Officer (Title) ❑ Partner(s) ❑ Attorney -in -Fact ❑ Trustee(s) ❑ Other' INSTRUCTIONS FOR COMPLETING THIS FORM Any acknowledgment completed in California must contain verbiage exactly as appears above in the notary section or a separate acknowledgment form must be properly completed and attached to that document. The only exception is if a document is to be recorded outside of California. In such instances, any alternative acknowledgment verbiage as may be printed on such a document so long as the verbiage does not require the notary to do something that is illegal for a notary in California (i.e. certifying the authorized capacity of the signer). Please check the document carefully for proper notarial wording and attach this form if required. a State and County information must be the State and County where the document signer(s) personally appeared before the notary public for acknowledgment. o Date of notarization must be the date that the signer(s) personally appeared which must also be the same date the acknowledgment is completed. o The notary public must print his or her name as it, appears within his or her commission followed by a comma and then your title .(notary public). ® Print the name(s) of document signer(s) who personally appear at the time of notarization. © Indicate the correct -singular or plural forms by crossing off incorrect forms (i.e. he/she/the} is /are ) or circling the correct forms. Failure to correctly indicate this information may lead to rejection of document recording. a The notary seal impression must be clear and photographically reproducible. Impression must not cover text or lines. If seal impression smudges,, re -seal if a sufficient area permits, otherwise complete a different acknowledgment form. , a Signature of the notary public must match the signature on file with the office of the county clerk. Additional information is not required but could help to ensure this acknowledgment is not misused or attached to,a different document. Indicate title or type of attached document, number of pages and date: Indicate the capacity claimed by the signer. If the claimed capacity is a corporate officer, indicate the title (i.e. CEO, CFO, Secretary). m Securely attach this document to the signed document C 2004-2015 ProLink Signing Service, Inc. — All Rights Reserved www.TheProLinkcom — Nationwide Notary Service