B-2017-1885 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2017-1885
20375 CLIFDEN WAY CUPERTINO,CA 95014-4460(369 37 011) A G H U S A INC
FREMONT,CA 94538
OWNER'S NAME: DATE ISSUED:03/29/2018
OWNER'S PHONE: PHONE No:(
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class B Lie.#99fi314 BLDG X ELECT_PLUMB
Contractor A G H U S A INC Date 08/31/2018
I hereby affirm that I am licensed under the provisions of Chapter 9(commencing —MECH YX 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:
1 ST FLOOR MASTER BEDROOM ADDITION(452 S.F.);RELOCATE
I hereby affirm under penalty of perjury one of the following two declarations; GARAGE DOOR OPENING TO THE FRONT;(N)DETACHED WOOD
r. I have and will maintain a certificate of consent to self-insure for Worker's DECK IN FRONT YARD(372 SF);(N)ATTACHED REAR DECK(280
Compensation,as provided for by Section 3700 of the Labor Code,for the S.F.);ELECTRICAL PANEL UPGRADE(400 AMP);(N)EV CHARGER
performance of the work for which this permit is issued. IN GARAGE(100 AMP).
2. 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 Flom Area:452 Venation:$100000.00
APPLTCANT 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 36937 011 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 03/29/2018 Issued by:Jasmine Archbold
/ Date:03/29/2018
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Lav£or are of the RE-ROOFS,
following two reasons: All roof's shall be inspected prior to any roofing material being installed.If a roof is
L 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(See.7044,Business&Professions Code)
z. 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:03/29/2018
1 hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
t. 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 Bre
Section 3700 of the Labor Code,for the performance of the work fmwhich 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
3. 1 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..play n son in an so as to become subject to the material.Additionally,should I use equipment or devices which emit hazardous
p y a y per y manner J air contaminants as defined by the Bay Area Ali 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 31 authorized agent:his
PLICAN't'CERTIFICATION Date:03!29/2018
I certify that I have read this application and State that the above information is CONSTRU TI E ING 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. I understand my plans shall be used as public records.
Licensed
Signature Date 03/29/2018
Professional
SMA
NO FEE FOR RECORDING PURSUANT TO
G®VERNM&NT CODE SECTION 27383
When Recorded Mail To:
City of Cupertino
Community Development Department
10300 Torre Avenue
Cupertino, CA 95014
24057660
Regina A b oormendras
Santa Clara County - Clerk -Recorder
11/07/2018 12:41 PM
`titles: I Pages: 3
Fees: $,0.00
Taxes: 0
Total: 10.00
IliPAMMAg111 I" IN'111UNAK : `IWN AA 11111
PROPERTY OWNER S)b9
"F 11 r, r1
Owner's Signature
Ct U, L
Print Owner's Name
� 0�
Date
CITY AUTHORIZATION:
IZATION:
Ellen Yau, Associat r 1 er
v
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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 6L -JL J }
On NIN.I�61*2-64before me, J L -UL LA- ,�
(Here insert name and tit16 of the officer) (J
personally appeared" I
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 cepacity(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 laws of the State of California that
the foregoing paragraph is true and correct.
JULIA?KIBdPY
WITNESS my hand and official seal.
oWi4i 77.456
Notary\8ublic Signature (Notary Public Seal)
®� II®��� ®STI®��� ���®�i�Il�TI®� INSTRUCTIONS FOR COMPLETING THIS FORM
This form complies with current California statutes regarding notary wording and,
DESCRIPTION OF THE ATTACHED DOCUMENT if needed should be completed and attached to the document. Acknowledgments
��n���A. from other states may be completed for documents being sent to that state so long
g V "`'S�1 1�. as the wording does not require the California notary to violate California notary
�or'Q"!
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CALIF® IA ALL-PURPOSE CER'TIFICAT'E OF ACKNOWLEDGMENT
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 S Q Al 4-'t C 1,t P-0,
On 0 2-o before me d� (`mss e UCL r- Notary Public
V�e�lses 7, l � � �l �-f c, � Y
(Here insert name and title of the officer) -
I
personally appeared t I S t vi
who proved to me on the basis of satisfactory evidence to be the person(Js whose name(s) is/are subscribed to
the within instrument and acknowledged to me that he/she/they executed the same m" 9s/her/ heir 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(sJ 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.
by _;ryf KIR$TEN SQUARCIA'
�: s Notary Public - CaliforniaSanta
WITNESS my hand and official seal. Z ;=
Clara County
Commission # 2257322
°Ax,FoaN" My Comm. Expires Oct 4,
2022
(Notary Seal)
Signature of Notary Public
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(Title or description of attached document) 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
(Title or description of attached document continued) document carefully for proper notarial wording and attach this form if required:
G State and County information must be the State and County where the document
Number of Pages Document Date 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. .
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commission followed by a comma and then your title (notary public).
o Print the name(s) of document signer(s) who personally appear at the time of
notarization.
CAPACITY CLAIMED BY THE SIGNER Indicate the correct singular or plural forms by crossing off incorrect forms (i.e.
he/she/&e}%- is /are ) or circling the correct forms. Failure to correctly indicate this
❑ Individual (S)
information may lead to rejection of document recording.
❑ Corporate Officer o 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
(Title) sufficient area permits, otherwise complete a different acknowledgment form.
❑ Partner(s) a Signature of the notary public must match the signature on file with the office of
the county clerk.
❑ Attorney -in -Fact o Additional information is not required but could help to ensure this
❑ Trustee(S) acknowledgment is not misused or attached to a different document.
❑ OtherIndicate 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).
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