B-2018-0926 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2018-0926
10218PARK CIRCLE E APT 2 CUPERTINO,CA 95014-1958(32632008) OWNER/BUILDER
OWNER'S NAME: DATE ISSUED:05/30/2018
OWNER'S PHONE: PHONE NO:
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class Lia#
Contractor OWNERIBUILDER Date 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 full farce and effect. JOB DESCRIPTION:
REPLACE WALL HEATER LIKE FOR LIKE SAME LOCATION
I hereby affirm under penalty of perjury one of the following two declarations;
r. 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.
z 1 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. Sq.Ft Fluor Area: Valuation:$2000.00
APPLICANT CF.RTIFICATiON
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 32632009
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 05-30-2018 Issued by:Kim Dunbar
Date:05/30/2018
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Cadractor's License Law far one of the RE-ROOFS:
1'a1lnwhng two reasons: All roofs shall be inspected prior to any roofing material being installed.Ia roof is
L 1,as owner of the property,or my employees with wages as their sole nstelled without fust 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(See.7044,Business&Professions Code)
1,as owner of the property,am exclusively contracting with licensed Signature of Applicant
or tmetots to construct the project(Sec.7044,Business&Professions Code). Date:05-30-2018
re affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
(a I have and will maintain a Certificate oP Consent to self-insure Por Worker's
Compensation,as provided for by Section 3700 of the Labor Code,for the
Ina formance of the work for which this permit is issued. HAZARDOUS MATERIALS DISCLOSURE
z. I have and will maintain Worker's Compensation Insuranc,m provided fur by I have react tire hazardous materials requirements under Clmptei 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 complinnce 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(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 1
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,1 become subject to the Worker's Compensation provisions of the the Health&Safety Code, coons 25505,2 ,xad 25534.
Labor Code,I must forthwith comply with such provisions or this permit shall
be deemed revoked. Owner or authorized agent:
APPLICANT CERTIFICATION Date:05-30-2018
I certify that I have read this application and state that the above information is CONSTRUCTION LENDING AGEN Y
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 publ o records.
Llcenand
Signature Date 05-30-2018 professional
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
Is
10300 TORRE AVENUE.CUPERTINO,CA 95014-3255 B '
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(408)777-3228• building@cupertino.org PEh4IT eB- O 19 242
-
CUPERTINO' REV a'_ DEF;_
❑NEW CONSTRUCTION ❑ADDITION 0 ALTERATION❑T.I. ❑DgP ❑RE-ROOF ❑SWIMMING POOL/SPA
PROJECTADDRESS APNk
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OWNERNAME PHONE
"
STREETADDRESS ICTY,STA ZIP
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❑CONTRACIORNAMB XO14'NER-BUILDER COh4PANYNA3,IE LICENSE NUMBER LICENSE TI'Pfi
STREET ADDRESS CITY,STATE,ZIP
E-MAIL (PHONE BUS.LIC I
❑ARCHITECT ❑OWNER❑OWNER AGENT O CONTRACTOR AGENT ENGN.EER DEVELOPERD TENANT
CONTACT NAME E-MAIL
STREET ADDRESS CITY,STATE,ZIP PHONE
DESCROTUN
?Q lace Wait ter e1n RKA`s1ltic
❑SINGLE-FAvIILY/DUPLEX 1( -FAMILY ❑INDUSTRIAL ❑COMMERCIAL
EXISTINGUBE EXIBTINGSF h'EWFLOORSF PORCHSF DECRSF DEMO SF STORIESF TOTAL NET IF USE TYPE OCC I 'SQ.FT. VALUATION($)
REMODEL REMODEL KITCHEN REMODEL OTHR GARAGB ATTACHED
BATHROOM IF IF SF IF DETACHED
EXISING ❑YES EICHLER EJ YES SECOND STORY ADDITION YES
FIRE SPIt1NKLEP.S NO ❑NO El No
DWELLING SECONDDWELLING [:]Y'ES❑ATTACHED❑DETACHED OTHER
UNITS! UMTADDHON: ElNO SF
POOLS ❑FIBERGLASS El NMnl-LINED ❑GUNITE [j PREFABRICATED
POOL-SF SPA-SF— I SPAATTACHED❑YES ❑NO TOTAL-SF
RECEIVE. TA VALUAT>,ON:
Commercial m,MOO-Famil B'ld' Yh P N'S F P 1 D T t I E- t 1 H 0 -I I* lfr_lj/7
RP-ROOF EXISTINGROOFTYPE: E-]BUILT-UP ROOF ASPHALT SHINGLES[]WOOD SHAKES❑WOOD SHINGLES❑TILE OTHER(SPECIFY)
REMOVE/REPL4CE❑NO I WIND PLYWOOD ❑'""' ❑3/8" PLYWOOD TYPE: PITCH: ROOF CLASS
❑YES R OF LAYERS_ THICKNESS❑5/8" OTHER_ DOSE ❑CDX OTHER 12 A
PROPOSED ROOF TYPE:OBUILT-UP ROOF❑ASPHALT SHINGLES O WOOD SHAKES DWOOD SHINGLES 11OTHER
'Provide a signed copy of the Cupertino's Tear-Off Policy SF €of SQUARES
By my signature below I certify to each of the following: I am the propertl,owner or authorized agent to act on the property owamer's behalf.I
have read this application and the information I have provided is correct.I have read the Descripfion of Work and Verify it is accurate.I agree
to comply with all applicable local ordinances and state laws relating to building construction. I authorize representatives of Cupertino to
enter the above-identified property for' es. I acknowledge mid authorize all information containedon tltis a�+ylication form
to be made available for public re 0_\6j�'7
Signature of Applicant/Agent: Date: pI �f
SUPPLEMENTAL INFORMATI REQUIRED
`Alew SFD/Second Dra'elling Units/HQultifamil),Dwellings:A Demolition permit is required prior to issuance of a building permit for all new construction.
"Commercial Buildings:Provide a completed Hazardous Materials Disclosure form if any Hazardous Materials are being used as part of this project.
`Copy of Plaarning Approval Letter or Meeting with Planning prior to submittal of Building Permit application.
"HOA-Provide a letter of approval from the Home Owner's Association
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