B-2018-0204 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR; PERMIT NO:B-2018-0204
22465 PALM AVE CUPERTINO,CA 95014-2711(357 03 068) KUBRO
CONSTRUCTION
CUPERTINO,CA 95014
OWNER'S NAME: DATE ISSUED:06/14/2018
OWNER'S PHONE: PHONE NO:(408)839-5800
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class @ Lic.#960307
Contractor KUBRO CONSTRUCTION Date 04/30/2019 X BLDG ELECT_PLUMB
I hereby affirm that I am licensed under the provisions of Chapter 9(commencing —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:
CONSTRUCTA DETACHED SECOND DWELLING UNIT(425 SF).
I hereby affirm tinder penalty of perjury one of the following two declarations:
1. 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.
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I"
hative and will maintain Worker's Compensation hump once,as provided for by
Secon 3700 of the Labor Code,for the performance of the work for which this
permit is issued. Sq.Ft Floor Arco:425 Valentina:$90000.00
APPLICANT CERTIRiCAT[ON
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 357 03 068 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 Co e,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
Signatur a -14-2018 Issued by:Kim Dunbar
Date:06/14/2018
I hereby affirm that I am exempt from the Contrnetm's License Law fm•one of the RF ROOFS:
fallowing two reasons: All roofs shall be inspected prior to any roofing material being installed.If a mof is
r. 1,as owner of the property,or my employees with wages as their sole installed without first obtaining an nspection,I agree to remove all new materials for
compensation,will do the work,and the structure is um intended at offered for inspection.
Sole(Sce.7044,Business&Professions Code)
z I,as owner of the property,am exclusively contracting with licensed Signature fApplicant:
contractors to construct the project(Sec.7044,Business&Professions Code), Date:06-14-2018
1 hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
i. 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 ofthe 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 rend the hazardous materials requirements mrder 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 Cade,Chapter 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 I stoic o-handle hazardous
shall not employ any person in any manner so as to become subject to the material.Additionally,should 1 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,1 must forthwith comply with such provisions or this permit shall
be deemed revoked. Owner or authoriz
APPLICANT CERTIFICATION Date:06-14-2018 ----__.--
I certify that I have read this application and state that the above information is CO-NS`FRf)C'�IAPJ�I7F'1"VDING 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 indemnity 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.
no my plans shall be used as public records.
Signature Date 06-14-2018 Licensed
Professional
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2018-0204
22465 PALM AVE CUPERTINO,CA 95014-2711(357 03 068) KUBRO
CONSTRUCTION
CUPERTINO,CA 95014
OWNER'S NAME:Santos Robert J And Janice C DATE ISSUED:06/14/2018
OWNER'S PHONE: PHONE NO:(408)8395800
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class GENERAL BUILDING CONTRACTOR Lie.#960307
Contractor KUBRO CONSTRUCTION Date 04/30/2019 X BLDG—ELECT—PLUMB
I hereby affirm that I am licensed under the provisions of Chapter 9(commencing —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:
CONSTRUCTA DETACHED SECOND DWELLING UNIT(425 SF).
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 REVISION#1-REVISE ADU LOCATION AND SIZE(422 SQ FT)DUE
Compensatioman,as provided for by Section 3700 of the Labor Code,for the TO SURVEY-ISSUE 7-20-2018
perfornce of the work£or which this permit is issued.
1 have and will maintain Worker's Compensation Insurance,as provided for by
Section 3700 of the Labar Code,for the performance of the work for which this
permit is issued. Sq.Ft Floor Area:425 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 slate laws relating to building construction,and hereby authorize 35703 068 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 regulatioonn) per the Cupertino Municipal Code,Section 9.18, 180 DAYS FROM LAST CALLED INSPECTION.
Signature ✓ -" Date Issued by:Kim Dunbar
Date:06/14/2018
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 n roof is
r. I,as owner ofthe property,o my employees with wages as their sole installed without first obtaining an nspection,I agree to remove all new materials fol'
compensation,will do the work,and the sta ecmre is not intended or offered for inspection.
sale(Sec.7044,Business&Professions Code)
2. 1,as owner of the property,am exclusively contracting with licensed Signature of Applicant
contractors to construct the project(Sec.7044,Business&Professions Code). Date:
I hereby affirm under penalty fperjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
r. I have and will maintain it Certificate of Consent to self-insure for Wori
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
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 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 t store or handle hazardous
shall not employ person in subject material.Additionally,should I use equipment ah•devices which emit hazardous
p yuny pe any manner so as to become J 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 became subject to the Worker's Compensation provisions of the the Health&Safety Cade,Sectio 25505,25533,and 25534.
Labor Code,l must forthwith comply with such provisions or this permit shall
be deemed revoked. Owner or authorized agent:
APPLICANT CERTIFICATION Date:
I certify that I have read this application and stale 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 MunicipalARCI 11TEC1'S DECLARATION
Code,Section 9.18. 1 understand my plans shall be used as public records.
Licensed
Signature Date
Professional