B-2017-1778 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:13-2017-1778
1189 YORKSHIRE CT CUPERTINO,CA 95014-4967(362 I 1007) PROVISION
DEVELOPMENT INC
SUNNYVALE,CA
94085
OWNER'S NAME: DATE ISSUED:05/23/2018
OWNER'S PHONE:408-255-5634 PHONE NO:(408)245-0991
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class B Lie.#858391
Contractor PROVISION DEVELOPMENT INC Date 0 5/3 112 01 9 X BLDG X ELECT X 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:
ADDITION(488 SF);REMODEL(2)BATHROOMS(100 SF);REPLACE
I hereby of Ian under penalty of perjury one of the following two declarntions: FURNACE SAME LOCATION;
1. 1 have and will maintain a certificate of consent to self-insure for Worker's CONVERT(1)BATHROOM TO LAUNDRY ROOM,NEW HALLWAY
Compensation,as provided for by Section 3700 of the Labo Code,for the (100 SF);PANEL UPGRADE(200 AMPS)
performance of the work fen which this permit is issued.
z. 1 have and will maintain Worker's Compensation Insurance,as provided for by
Section 3700 orthe Labor Code,for the performance of the work fur which this
permit is issued Sq.Ft Flanr Area:488 Yaluatimn:$120000.00
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 362 11 007 R-3(Custom)
representatives of this city to enter upon the above mentioned propeerrtt to
inspection purposes. (We)agree to save indemnify and ke p-hat'fRes t#t�
City of Cupertino against liabilities,judgments,cots-ate ape . hIch PERMIT EXPIRES IF WORT{IS NOT STARTED
may accrue against said City in conseque��ntee oflhe gran of this permit. WITHIN 180 DAYS OF PERMIT ISSUANCE OR
Additionally,the applicant unders nd�and will co I with all non-point
source regulations per the ertino Muriel a ode,section 9,18. 180 DAYS FROM LAST CALLED INSPECTION.
Signalur ate 05/23/2018 Issued by:Jasmine At
Date:05/23/2018
OWNER-RUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Low for one a]the RE-ROOFS:
following two reasons; All roofs shall be inspected prior to any roofing material being installed Ifs roof is
v I,as owner of the property,or my employee.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 or offered for inspection.
sale.(Sce.7044,Business&Professions Code)
z. I,as owner ofOne property,am exclusively contracting with licensed Signature ofApplicant:
contractors to construct the project(See 7044,Business&Professions Code). Date:05/23/2018
I hereby affirm under penalty of perjury one of the following three declarations: pLL ROOF COVERINGS TO BE CLASS"A"OR BETTER
i. I have and will maintain a Certificate of Consent to self-insure for Workcr's
Compensation,as provided for by Section 3700 of the Labor Cade,fur 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 far by I have read the hazardous materials requirements under Chapter 6.95 of the
Section 3700 of the Labor Code,for the perf rmauce of the work for which this California Health&Safety Code,Sections 25505,25533,and 25534.1 will
permit is issued. maintain romplLmce with the Cupertino Municipal Code,Chapter 9.12 and the
s. 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 r handle hazardous
shat]not employ son in an so as to become subject to the nmterinl.Additionally,should 1 use equipment or devices which emit loven,ens
p y any per y manner J air centsninants as defined by the Bay Area pin Quality Mamnge�Disfn"�
Worker's Compensation laws of California.If,after making this certificate of win maintain compliance with the Cup tino Munfdp d e; mfpt •AT and
exemption,I become subject to the Worker's Compensation provisions of the the Health&Safety Code,Sections 25 5,A 3,r a U.
Labor Code,I must forthwith comply with such provisions or this permit shall
be deemed revoked. Owner or authorized a nt.
APPLICANT CERTIFICATION Date: 2
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 h e affirm that there is a construction lending agency for the performance
relating to building construction,and hereby authorize representatives of this ci y work's for which this permit is issued(Sec.3097,Civ C,)
to enter upon the above mentioned property for inspection purposes. (W��)-gree Lender's Name
to save indemnify and keep harmless the City of Cupertino.against Iia i�ities,
judgments,costs,and expenses which may accrue against s id'Ey in Lender's Address
consequence of the granting of this permit.Additionally,in applicant understands
and will comply with all non-point source regulations per the Cupertino Municipal ARCH 1'1'ECT'S DECLARATIOry
Code,Section 9.18. 1 understand my plans shall be used as public records.
Liceed
Signature Data 05/23/2018 ns
Professional
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2017-1778
1189 YORKSHIRE CT CUPERTINO,CA95014-4967(362 11 007) PROVISION
DEVELOPMENT INC
SUNNYVALE,CA
94085
OWNER'S NAME: DATE ISSUED:05/23/2018
OWNER'S PHONE: PHONE Nth(408)245-0991
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class¢ Lic.#858391
Contractor PROVISION DEVELOPMENT INC Date 05/31/2019 X BLDG X ELECT X PLUMB
MECH?X RESIDENTIAL_,COMMERCIAL
I 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:
ADDITION(488 SF);REMODEL(2)BATHROOMS(100 SF);REPLACE
I hereby affirm under penalty of perjury one of the following two declarations: FURNACE SAME LOCATION;
1. I have and will maintain a certificate of consent to self-insure for Worker's CONVERT(1)BATHROOM TO LAUNDRY ROOM,NEW HALLWAY
Compensation,as provided for by Section 3700 of the Labor Code,for the (100 SF);PANEL UPGRADE(200 AMPS)
performance of the work for which this permit is issued. REV#1-REWIRE WHOLE HOUSE;RE-PIPE WATER(7 FIXTURES);
is issued. OFF;INSTALL OSB;COMP SHINGLES(3,240 SF)-ISSUED 2-22-2019
APPLICANT'CERTIFICATION Sq.Ft Floor Area:488 Valuation:$120000.00
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
and state laws relating to building construction,and hereby authorize APN Number: Occupancy Type:
representatives of this city to enter upon the above mentioned property for 362 11 007 - R-3(Custom)
inspection purposes. (We)agree to save indemnify and keep harmless the
City of Cupertino against liabilities,judgments,costs,and ses which
may accrue against said City in consequence oft a .kit—of this permit. PERMIT EXPIRES IF WORK IS NOT STARTED
Additionally,the applicant understands an•-will co,•y with all non-point
source regulations per the Cuperti e uni c- Code,Section 9.18. WITHIN 180 DAYS OF PERMIT ISSUANCE OR
2— -2019
Issued by:Jasmine Archbold
016 .R-BUILDER DECLARATION Date.05/23/2018
I hereby affirm that I am exempt from the Contractor's License Law for one of the
following two reasons: RE-ROOFS:
1. I,as owner of the property,or my employees with wages as their sole All roofs shall be inspected prior to any roofing material being installed.If a roof is
compensation,will do the work,and the stricture is not intended or offeredfor installed without first obtaining an inspection,I agree to remove all new materials for
sale(Sec.7044,Business&Professions Code) inspection.
2. 1,as owner of the property,am exclusively contracting with licensed
contractors to construct the project(Sec.7044,Business&Professions Code). Signature of Applicant:
I hereby affirm under penalty of perjury one of the following three declarations: Date:2-22-2019
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 ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
performance of the work for which this permit is issued.
2. I have and will maintain Worker's Compensation Insurance,as provided for by HAZARDOUS MATERIALS DISCLOSURE
Section 3700 of the Labor Code,for the performance of the work for which this I have read the hazardous materials requirements under Chapter 6.95 of the
permit is issued. California Health&Safety Code,Sections 25505,25533,and 25534. I will
3. 1 certify that in the performance of the work for which this permit is issued,I maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
shall not cmploy.any person in any manner so as to become subject to the Health&Safety Code,Section 25532(a)should I store or handle hazardous
Worker's Compensation laws of California. IL after making this certificate of material. Additionally,should I use equipment or devices which emit hazardous
air contaminants as defined by the Bay Area Air Quality Management s
Labor Code,I must forthwith comply with such provisions or this permit shall will maintain compliance with the
,
relating to building construction,and hereby authorize representatives of this city I hereby_ir hat there is a construction lending agency for the performance
to enter upon the above mentioned property for inspection purposes. (We)agree of w res for which this permit is issued(Sec.3097,Civ C.)
to save indemnify and keep harmless the City of Cupertino against liabilities, nder's Name.
judgments,costs,and expenses which may accrue against said City in
consequence of the granting of this permit. Additionally;the applicant understands Lender's Address
and will comply with all non-point source regulations per the Cupertino Municipal
Code,Section 9.18. ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Signature Date 2-22-2019
Licensed
� 1 .
r . ,
CON TRUCTION PERMIT APPLIC.ATI N t k ` ,
,,.,::0.,,..„. ....
„..,.
j COMMUNITY.DEVELOPMENT DEPARTMENT • BUILDING DIVISION B .
. : 1030%TORRE AVENUE e CUPERTINO,CA 95014-3')55
(408)777-3228 s. buiiding@cupertino.org PERMIT#B /"- /7-16CUP ;'
Ti i REV- J DEE g
El NEW CONSTRUCTION 0ADDTTION El ALTERATION T.I- 0 MEP 0 RE-ROOF ❑ SWIMMING POOL/SPA
PROJECT ADDRESS APtv._
OWNER NAME ¢ PHONE E..m...AIL �
119-1: '� ,, I T�c ;) b'-f*`� .'d.-�" ".401 (0��—� (r ret b` `34,w ��� ,', ;,i ',,,,, �"'47A��,
"'I•R.{T ADDIW:ss d ' CITY STATE ZIP -Y �� ,�.
1 '
" a ' I1..t `' 'J;r>'a, r .. '�
].CONTRACTURNAME 0OWivt'.R-RUILDEK COMPANY NAME ;..ICENSLNUMBER LICENSE TYPE
,,€€ 1 rw
slam.AI.70R tis I 4:4/6_5-- CITY„TATE, ZIP M_
_,,<-1 ,.. 2e 4"1"17'all -''t 1 -S'< elegy _ Cc 'k,�, .'4. .,, `°' 'e9 '`;.
:E-MAIL. a PHONE ” •
BUS. __._._-....__._..__•
0 ARCHITECT ❑OWNER 0OWNER AGENT 0 CONTRACTOR AGENT ENGINEER 0 DEVELOPER 0 TENANT
coNTAcr NAME .r
o y F-NC II
" .,.,..m. `'F ..y '1-.,,"T. d YG tea.^ t, fs ,a� l € ="g�$ .' `
STREET ADDRESS COY,STATE,ZIP PHONE
/ - ~ � , .. ,..44"....e,- , ) � 2t „e4 -< .. ---- /2r `
DEs�RlrTON _ _ �
lcto Y--,-5,1/4I I* i� l a Pfd° 6109 12 ' l'vi ' I 4rz- 1, trs ,/
-c'a' rz_ Cl/I1 U ° 25'l lc- 1 V`) ,7_ (ANC) ' iziTe4ri = 1 g
3
1
DSINCLE F.AMIL:Y/DUPLT.X 0MUL.TI-FAMILY 0 INDUS'i'RlAL ❑COMMERCIAL,
EXISTING USE EXISTING SE NEW FLOOR SF PORCH SF DECK SP DEMO SF SIM 554: TOTAL NE-FSI USE I TYPE UCC., ; S:?.PT. VALUATION./.$)
I
REMODEL REMODEL KITCHEN REMODEL CYI'HIL GARAGE ❑ATTACHED
BATHROOM SE SP- SF SEs • 0 DETACHED
EXLSING 0 YES 51011 ER El YES SECOND STORYADDITION 0 YES
LIRE>PRINKI..E.RS.0 NO 0 NO 0 NO
DWELLING S'C c)NU DWELLING 0 YES 0 AT5ACIIED 0 DETACHED OTHER
UNITS 3 UNIT ADDITON: 0 NO S P
POOLS) [t FIBERGLASS 0 VINYL—LIN ED 0 citiltirts 0 PREFABRICATED A'rED ®
POOL SE SPA•SF I SPA ATTACHED D YES ❑NO I. TOTAL SIS 7^ 1 '/
RECE IV,`I I 1
1 kit-x."4,--.
p ;iz '1�)1:1L VALUATION:
c viNS r r r gth h rerrn hr Sridde n with F s hr 5.n„?zn i i Pools requires L') el-b eet ofEnvironmental He i�h«?.-r,m% 'X n,,,.; f
RE ROi"E i XI PNG R00 TYPE: ne.BUILT-UP ROOF ASPH OF SHINGLES{WOOD SHAKES WOOD SHINGLES C 1.ES(]IILE OTHER(SPECIFY) T
REMOVE/REPLACE®NO I"NO 1PI,.YWOO1) in 0 3/r P1 ATOOD IYI r.: PITCH: 4 IU)OI CLASS
COyI:S OF LAYERS rf{IC.KN1.S.S Q Si OTHER .__.4 I^IUSB 0 CLX OTHER. -..4- 12 "A
PROIOSEDROOF TYI'E:DBI AT I IUPR()()I DASPHALT sHrNo 15S 0WOODSI.IAKES aWOODSI-TING S DOTTIER,__,_,_. _
ter.
*Provide a signed cl Copy of the Cupertino spear-Off Policy-
u.:,-l'''',:„.. '{3 Cr
ai 'L 1ILF 5_.
By my signature below I certify to each of the following: I am the property t syne o au thorizc d agent to act on the property owner's behalf. I
have read this application and the information I have provided-iSi orrec"t I'have read the Description of Work and verify it is accurate. I agree
to comply with all applicable local ordinances and state#7.aws rel3tiiig to building construction. I Authorize representatives of Cupertino to
enter the above-identified property for Inspection purpo_ s T'acI<nowled:ge and authorize all information contained on this application form
to be made available for public record. ,arm'
e
Signature of Applrc ant/Agent _— - " -° "-._.. Date: ._.;.S -
SUPPLEMENTAL iNFORMATiON PEQUIREi3_r J
"New SFD/Second-Dwelling Units/Multifamily Dwellings:A Demolition permit is required prior to issuance of a building permit for allnew construction,
'Commercial B'.Llildings: Provide a completed i'{azardOus Materials Disclosure form it'any Hazardous Materials are being used as part of this project...
*Copy of Planning Approval Letter or Meeting with Planning prior to submittal of Building Permit application.
"HOA-Provide a letter of approval from the Rome Owner's Association j '
ly -
l€,
BdApp_ O1t7.dor revised 08/0 11 1
•
O NA.vk,es OTC '-&-. 1
A-''''_ :.:eA•