13120099CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 22445 CUPERTINO RD
CONTRACTOR: SAMUEL PERMIT NO: 13120099
CONSTRUCTION
OWNER'S NAME:
2141 CAROBWOOD LN DATE ISSUED: 10/09/2014
OWNER'S PHONE: 4084545600
SAN JOSE, CA 95132 PHONE NO: (408) 221-7900
LICENSED CONTRACTOR'S DECLARATION
JOB DESCRIPTION: RESIDENTIAL COMMERCIAL E]
SUNNY VIEW RETIREMENT HOME - RECONFIGURE
License Class_ Lic. #C p ? 7 Z
COMMON
AREAS FOR BLDG #5, M.E.P.'S FOR OFFICES,
Contractor g?pe-yl E>4L t V dL Date l 001
.INCLUDING
ACTIVITY ROOM & FOOD SERVING AREA
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.
I hereby affirm under penalty of perjury one of the following two declarations:
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
Sq. Ft Floor Area:
Valuation: $60000
performance of the work for which this permit is issued.
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
APN Number: 32615130.22445
Occupancy Type:
permit is issued.
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is
PERMIT EXPIRES IF WORK IS NOT STARTED
correct. I agree to comply with all city and county ordinances and state laws relating
WITHIN 180 DAYS O SUANCE OR
to building construction, and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We) agree to save
180 DAY L INSPECTION.
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
costs, and expenses which may accrue against said City in consequence of the
millillued by: Date:
granting of this permit. Additionally, the applicant understands and will comply
_
with all non -point source regulations per the Cupertino Municipal Code, Section
9.18. �
Signature - Date % O 1?
RE -ROOFS:
All roofs shall be inspected prior to any roofing material being installed. If a roof is
installed without first obtaining an inspection, I agree to remove all new materials for
inspection.
❑ OWNER -BUILDER DECLARATION
Signature of Applicant: Date:
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
I, as owner of the property, or my employees with wages as their sole compensation.
will do the work, and the structure is not intended or offered for sale (Sec. 7044,
Business & Professions Code)
I, as owner of the property, am exclusively contracting with licensed contractors to
HAZARDOUS MATERIALS DISCLOSURE
construct the project (Sec.7044, Business & Professions Code).
I have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533, and 25534. I will
I hereby affirm under penalty of perjury one of the following three
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
declarations:
Health & Safety Code, Section 25532(a) should I store or handle hazardous
I have and will maintain a Certificate of Consent to self -insure for Worker's
material. Additionally, should I use equipment or devices which emit hazardous
Compensation, as provided for by Section 3700 of the Labor Code, for the
air contaminants as defined by the Bay Area Air Quality Management District I
performance of the work for which this permit is issued.
will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance, as provided for by
the Health & Safety Code, Sections 25505, 25533, and 25534.
Section 3700 of the Labor Code, for the performance of the work for which this
Owner or authorized agent: �" �' Date: l t3 �
permit is issued.
I certify that in the performance of the work for which this permit is issued, I shall
not employ any person in any manner so as to become subject to the Worker's
Compensation laws of California. If, after making this certificate of exemption, I
CONSTRUCTION LENDING AGENCY
become subject to the Worker's Compensation provisions of the Labor Code, I must
I hereby affirm that there is a construction lending agency for the performance of
forthwith comply with such provisions or this permit shall be deemed revoked.
work's for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
APPLICANT CERTIFICATION
Lender's Address
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 representatives of this city to enter
upon the above mentioned property for inspection purposes. (We) agree to save
ARCHITECT'S DECLARATION
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
costs, and expenses which may accrue against said City in consequence of the
I understand my plans shall be used as public records.
granting of this permit. Additionally, the applicant understands and will comply
with all non -point source regulations per the Cupertino Municipal Code, Section
Licensed Professional
9.18.
Signature Date
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:13120099
22445 CUPERTINO RD CUPERTINO CA 95014(326 15 130) SAMUEL
CONSTRUCTION
SAN JOSE,CA 95132 -
OWNER'S NAME: DATE ISSUED:10/09/2014
OWNER'S PHONE:( PHONE NO:(
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class GENERAL BUILDING CONTRACTOR Lid,#564772
Contractor 5AMUELrCONSTRUCTION Date 04/30/2019 _BLDG_ELECT_PLUMB
I hereby affirm that I am licensed under the provisions of Chapter 9(commencing —MECH—RESIDENTIAL_COMMERCIA.L
with Section 7000)of Division 3 of the Business&Professions Code and that my
license is in full force and effect. JOB DESCRIPTION:
I larch affirm under SUNNYVIEW RETIREMENT HOME-RECONFIGURE COMMON
y penalty of perjury one of the foliowing two declarations: AREAS FOR BLDG 45,INCLUDING M.E.R'S FOR OFFICES,
t. 1 have and will maintain a certificate of consent to self-insure for Worker's ACTIVITY ROOM&FOOD SERVING AREAREVISION#1-NEED
Compensation,as provided for by Section 3700 of the Labor Cade,for the APPLICATION: SITE ACCESSIBILITY AND DELAYED EGRESS
perfarramee of the work for which this permit is issued. DOORS."C" - ISSUED 6/19/18
I have and will maintain Worker's Compensation Insurance,as provided for by combine 3 areas in building#5(Daisy lane with 5192 ST,Sunflower lane
Section 3700 of the Labor Code,for the performance of the work for which this with 5116 S.F,and Activity building with 1027 ST),into one building
permit is issued. called "bldg 5"or"Summer House"with total square foot of 11335 ST,
APPLICANT CERTIFICATION by removing existing"Area separation wall"between Daisy&Sunflower
I certify that I have read this application and state that the above lane DEFERRED#1-CAN LIGHTS AT RATED CEILING-ISSD OTC
information Is correct.I agree to comply with all city and county ordinances 2/24/2015
and state laws relating to building construction,and hereby authorize
representatives of this city to enter upon the above mentioned property for
inspection purposes.(We)agree to save indemnify and keep harmless the Sq.Ft Floor Area: Valuation:$60000.00
City of Cupertino against liabilities,judgments,costs,and expenses which
may accrue against said City in consequence of the granting of this permit.
Additionally,the applicant understands and will comply with all non-point APN Number: Occupancy Type:
source regulations per the Cupertino Municipal Code,Section 9.18. 326 15 130
Signature Date PERMIT EXPIRES IF WORK IS NOT STARTED
OWNER-Bu > ER DE L TION WITHIN 180 DAYS OF PERMIT ISSUANCE OR
I hereby affirm that I am exempt from the Contractor's License Law for one of the 180 DAYS FROM LAST CALLED INSPECTION.
following two reasons;
t. I,as owner of the property,or my employees with wages as their sole Issued by:Legacy
compensation,will do the work,and the structure is not intended or offered for Date:10/09/2014
sale(3ec.7044,Business&Professions Code)
z. I,as owner of the property,am exclusively contracting with licensed
contractors to construct the project(Sec.7044,Business&Professions Cade). RE-ROOFS,
All roofs shall be inspected prior to any roofing material being installed,If a roof is
I hereby affirm under penalty of perjury one of the following three declarations: installed without first obtaining an inspection,I agree to remove all new materials for
r. I have and will maintain a Certificate of Consent to self-insure for Worker's inspection.
Compensation,as provided for by Section 3700 of the Labor Code,for the
per of the work for which this permit is issued, Signature of Applicank
z. I have and will maintain Worker's Compensation Insurance,as provided for by Date:
Section 3700 of the Labor Code,for the performanceo£the work for which this
perdu is issued, ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
s. I certify That in the performance of the work for which this permit is issued,I
shall not employ any person in any manner so as to become subject to the
Worker's Compensation laws of California.If,after making this certificate of HAZARDOUS MATERIALS DISCLOSURE
exemption,I become subject to the Worker's Compensation provisions of the I have read the hazardous materials requirements under Chapter 6.95 of the
Labor Code,I mus(forthwith comply with such provisions or this permit shall California Health&Safety Code,Sections 25505,25533,and 25534.1 will
maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
be deemed revoked, m Health&Safety Code,Section 25532(a)should I stare or handle hazardous
APPLICANT CERTIFICATION material,Additionally,should 1 use equipment or devices which emit hazardous
I certify that I have read this application and state that the above information is air contaminants as defined by the Bay Area Air Quality Management District I
correct.I agree to comply with all city and county ordinances and state laws will maintain compliance with the Cupertino Municipal Code,Chapter 9,12 and
relating to building construction,and hereby authorize representatives of this city the Health&Safety Code,Sections 25505,25533,and 25534,
to enter upon the above mentioned property for inspection purposes. (We)agree ��_�_�
to save indemnify and keep harmless the City of Cupertino against liabilities, Owner or authorized agent: •------
and will comply with all non-point source regulations per the Cupertino Municipal 1 hereby affirm that there is a construe n-IeadiH agency for the performance
Code,Section 9.18. of work's for which this permit is issued(Sec.3097,Civ C.)
Lender's Name -
Signature Date Lender's Address
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Licensed
Professional
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO: 13120099
22445 CUPERTINO RD CUPERTINO CA 95014 (326 15 130) SAMUEL
CONSTRUCTION
SAN JOSE, CA 95132
OWNER'S NAME: DATE ISSUED: 10/09/2014
OWNER'S PHONE: PHONE NO: (408) 221-7900
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class B Lic. #564772
Contractor SAMUEL CONSTRUCTION Date 04/30/2019 — BLDG — ELECT — PLUMB
MECH , 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:
SUNNYVIEW RETIREMENT HOME - RECONFIGURE COMMON
I hereby affirm under penalty of perjury one of the following two declarations: AREAS FOR BLDG #5, INCLUDING M.E.R'S FOR OFFICES,
1. I have and will maintain a certificate of consent to self-insure for Worker's ACTIVITY ROOM & FOOD SERVING AREA.
Compensation, as provided for by Section 3700 of the Labor Code, for the REVISION #2: Combine 3 areas in building # 5 ( Daisy lane with 5192 S.F,
performance-of the work for which this permit is issued. Sunflower lane with 5116 S.F, and Activity building with 1027 S.F ), into
I have and will maintain Worker's Compensation Insurance, as provided for by one building called "bldg 5" or "Summer House" with total square foot of
Section 3700 of the Labor Code, for the performance of the work for which this 11335 S,F , by removing existing" Area separation wall " between Daisy &
permit is issued. Sunflower lane. - ISSUED 12/11/2018
APPLICANT CERTIFICATION REVISION #1. - SITE ACCESSIBILITY AND DELAYED EGRESS
certify that I have read this application and state that the above DOORS. ISSUED 6/19/18
information is correct. I agree to comply with all city and county ordinances DEFERRED #l- CAN LIGHTS AT RATED CEILING- ISSD OTC
and state laws relating to building construction, and hereby authorize 2/24/2015
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 Sq. Ft Floor Area: Valuation: $60000.00
may accrue against said City in consequence of the granting of this permit.
Additionally, the applicant understands and will comply with all non-point
source regulations per the Cupertino Municipal Code, Section 9.18. APN Number: Occupancy Type:
326 15 1.30
Signature Date 12/11/2018
O ER-B DER DECLA PERMIT EXPIRES IF WORK IS NOT STARTED
�. .. .. �A IF WITHIN 180 DAYS OF PERMIT ISSUANCE OR
I hereby affirm that I am exempt from. the Contractor's License Law for one of the 180 DAYS FROM LAST CALLED INSPECTION.
following two reasons:
1. I, as owner of the property, or my employees with wages as their sole
compensation, will do the work, and the structure is not intended or offered for Issued by: Legacy
sale (Sec.7044, Business & Professions Code) Date: 10/09/2014
2. I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec.7044, Business & Professions Code),
RE-ROOFS:
I hereby affirm under penalty of perjury one of the following three declarations: All roofs shall be inspected prior to any roofing material being installed. If a roof is
1. I have and will maintain a Certificate of Consent to self-insure for Worker's installed without first obtaining an inspection, I agree to remove all new materials for
Compensation, as provided for by Section 3700 of the Labor Code, for the inspection.
performance of the work for which this permit is issued.
2. I have and will maintain Worker's Compensation Insurance, as provided for by Signature of Applicant:
Section 3700 of the Labor Code, for the performance of the work for which this Date: 12/11/2018
permit is issued.
3. I certify that in the performance of the work for which this permit is issued, I ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
shall not employ any person in any manner so as to become subject to the
Worker's Compensation laws of California. If, after making this certificate of
exemption, I become subject to the Worker's Compensation provisions of the HAZARDOUS MATERIALS DISCLOSURE
Labor Code, I must forthwith comply with such provisions or this permit shall I have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533, and 25534. I will
be deemed revoked, maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
APPLICANT CERTIFICATION Health & Safety Code, Section 25532(a) should I store or handle hazardous
certify that I have read this application,and state that the above information is material. Additionally, should I use equipment or devices which emit hazardous
correct. I agree to comply with all city and county ordinances and state laws air contaminants as defined by the Bay Area Air Quality Management District I
relating to building construction, and hereby authorize representatives of this city will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and
to enter upon the above mentioned property for inspection purposes. (We) agree the Health & Safety Code, Sections 25505, 25533, and 25534.
to save indemnify and keep harmless the City of Cupertino against liabilities,
judgments, costs, and expenses which may accrue against said City in Owner or authorized agent:
consequence of the granting of this permit. Additionally, the applicant understands Date: 12/11/2018
and will comply with all non-point source regulations per the Cupertino Municipal
CONSTRUCTI&N. LENDIN GENCY
Code, Section 9.18. I hereby affirm that there is a construct`i'•an ledi
nng a ency for the performance
of work's for which this permit is issued (Sec. 3D} , Civ C.)
Signature Date 12/11/2018 Lender's Name
Lender's Address