B-2018-0182 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2018-0182
10365 STERN AVE CUPERTINO,CA 95014-3643(375 10 054) FIRST
CONSTRUCTION
COMPANY
CUPERTINO,CA 95014
OWNER'S NAME: DATE ISSUED:05/11/2018
OWNER'S PHONE: PHONE NO:(408)966-2192
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class B Lic.#1025763
Contractor FIRST CONSTRUCTION COMPANY 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:
NEW 2 STORY HOME(1822 SF)WITH ATTACHED GARAGE(427.25
I 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 Floor Area: 1822 Valuation:$350000.00
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:
375
and state laws relating to building construction,and hereby authorize 375 10 054 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.
Signature Date 4/3/19 Issued by:Abby ede
Date:05/11/2018
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:4/3/19
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
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 agent:
APPLICANT CERTIFICATION Date:4/3/19
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. I understand my plans shall be used as public records.
Licensed
Signature Date 4/3/19 Professional
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2018-0182
10365 STERN AVE CUPERTINO,CA 95014-3643(375 10 054) FIRST
CONSTRUCTION
COMPANY
CUPERTINO,CA 95014
OWNER'S NAME: DATE ISSUED:05/11/2018
OWNER'S PHONE: PHONE NO:(
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class B Llc.#1025783
Contractor FIRST CONSTRUCTION COMPANY Date 04/30/2019 X BLDG_ELECT_PLUMB
I hereby offirm that I am licensed under the provisions of Chapter 9(commencing —MECH Z 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:
NEW 2 STORY HOME(1822 SF)WITH ATTACHED GARAGE(427.25
1 hereby affirm under penalty of perjury one of the following two declarations: SF)
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
I 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 Floor Area:1822 Valuation:$350000.00
APPLICANT CERTIFICATION
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 stale laws relating to building construction,and hereby authorize 375 10 054 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-polnt
source regulations per the Cupertino Municipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
Signature `' Date 5/11/2018 Issued by:AbbyAvende
Date:05/11/2018
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,m 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(Sce.7044,Business&Professions Code)
Z I,as owner of the property,am exclusively contracting with licensed Signature of Applicant:
contractors to construct the project(Sm,7044,Business&Professions Code). Data: 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, 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
* I have and will maintain Worker's Compensation Insurance,m 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 25534.1 will
permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
s. I certify that in the performance o£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 my 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 raking 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 most forthwith comply with such provisions or this permit shall
be deemed revoked. Owner or authorized agent:
APPLICANT CERTIFICATION Data:5111/2018
1 certify that I have read this application and state that the above Information Is CONSTRUCTION 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•publlc records.
icensed
Signature Date /115 /2018 L
Professional
'd FEE FOR RECORDING PURSUANT TO
GOVERNMENT CODE SECTION 27383
When Recorded Mail To:
City of Cupertino
Community Development Department
10300 Torre Avenue
Regina A 1 oomendras
Santa Clara County - Clerk -Recorder
03/18/2019 11:55 AM
Titles: I Pages: 3
Fees: 0.00
Taxes: 0
Total: 10.00
III WAJ1111170M, KINIPOAM MAWTI W py, W, 11111
Owner's Signature
Print Owner's Name
Date �,
CITY
CALO ORNBA ALL-PURPOSE ACKNOWLEDGMENT CIVIL CODE § 1189
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�
On [ " fArC,�., i y� % L before me, Lo cz� Saoc4gar-- A ]b 44 22
Date �t Here Insert Name and Title of the O)ficer
personally appeared t Q1, r_ I Or
Nome(s) of Signer(s)
who proved to me on the basis of satisfactory evidence to be th pens' (s) whose (s) 0/are subscribed
to the within instrument and acknowledged to me tha I/she/they executed the same in hit her/their
authorized(capaci (ies), and that by(yher/their ignature �s) on the instrument the erso (s), or the entity
upon behalf -57 -which the ers (s) acted, execute e instrument.
sw�°F,H LAUREN$APUDAR
s9 Notary Public = California
Z
Z R Santa Clara County
Z Commission # 2247155
""°°a > PAy Comm. Expires Jun Z2, 2022
Place Notary Seal and/or Stamp Above
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
V Signature of Notary Public
,0_1 MiIILAI 10I/M
Completing this information can deter alteration of the document or
fraudulent reattachment of this form to an unintended document.
Description of Attached Document rr .
Title or Type of Document: �t ��
Document Date: Lj Number of Pages:
Signer(s) Other Than Named Above:
Capacity(les) Claimed by Signer(s)
Signer's Name:
❑ Corporate Officer - Title(s):
❑ Partner - ❑ Limited ❑ General
❑ Individual ❑ Attorney in Fact
❑ Trustee ❑ Guardian of Conservator
❑ Other:
Signer is Representing:
02017 National Notary Association
1
Signer's Name:
❑ Corporate Officer -
❑ Partner - ❑ Limited
❑ Individual
❑ Trustee
Title(s):
❑ General
❑ Attorney in Fact
❑ Guardian of Conservator
❑ Other:
Signer is Representing:
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A i; I � I r.1,a �•� � r'� � I I — ��� , I�� ��� 5,'1''`, I i» � `*,
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 VALID-ITY OF THAT DOCUMENT.
State of California
}ss.
County of Santa Clara
On 1114& ('j0e J9 before me, Linda E. Lococo, Notary Public, personally appeared
r � � `j JAN6
who proved to me on the basis of satisfactory evidence
to be the persons whose names are subscribed to the
within instrument and acknowledged to me that they
executed the same in their authorized capacities,
and that by their signatures on the instrument the,
persons, or the entity upon behalf of which the. persons
acted, executed the instrument.
LINDA E. L00000
NotaryPublic-California Z I certify under PENALTY OF PERJURY under the laws of
zSanta Clara County
Commission # 2183307, the State of California that the foregoing paragraph is
My Comm. Expires Mar 12,202
true and correct..
ovoeeo—OPTION----------------
Though the information below is not required by law, it may prove valuable to persons relying on the document and
could prevent fraudulent removal and reattachment of this form to another document
Description of Attached Document
Title or Type of Document: AZZ65 ���� `���� 7P
Document Date: J-/4Number of Pages: 0,65,
Signer(s) other than named above: S/A&Y 'Poe)w figtt rjle'
Oapacity(iies) Clalmed by Signer(s)
Signer's Name:
❑ Individual
❑ Corporate Officer
Title(s):
❑ Partner --- ❑ Limited
❑ Attorney -in -Fact
❑ Trustee
❑ General
❑ Guardian or Conservator
❑ Other:
Signer is Representing
Signer's Name:
❑ Individual
❑ Corporate Officer
Title(s):
❑ Partner --- El Limited
❑ Attorney -in -Fact
❑ Trustee
❑ General
❑ Guardian or Conservator
❑ Other:
Signer is Representing