B-2018-1349NO FEE,FOR ECORDING PURSUANT TO
GOVERNMENT CODE SECTION 27383
When Recorded Twill To:
City of Cupertino
Community Development Department
10300 Torre Avenue
Cupertino, CA 95014
24240156
Regina A b oomendras
Santa Clara County - Clerk -Recorder
07/26/2019 01:27 PM
Titles: I Pages: 4
Fees:10.00
0.00
Taxes: 0
Total:
®III IA10% 0 K tiA �R INNIMAI KAM 11111
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PROPE TY Its �o
Owne ' S'gna e
Lee -
Pr' wner's Name
Date
CITY AUTHORIZATION:
&4401-- AV �&z
Erika Poveda, Assistant Planner
INSl 9 L? �_1 `:._ S �1
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 a N LgA(LA } yy
On 2--t n - before me, Q, kali Ch Iia pa-'--1ada Notary
Date Insert (Mame rind Title of the officer
Public, personally appeared 7.1 N r14() -W LC
Name(.p) of Signer(} -
who proved to me on the basis of satisfactory evidence to be the person(;) whose narne(e;) is/aid
subscribed to the within instrument and acknowledged to me that T-e-/sheftljeyexecuted the same in
,,Wrs/herjt - authorized capacity(i,&), and that by W1s/herjthtir signatureN on the instrument the
person(s., orthe entity upon behalf ofvvhich 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.
WITNESS my hand and official seal. BALAKRISHNA PEDADA
NotaryPublic- California Z
Q_.
Santa Clara County a
5 1kS'
Commission # 2181101
My Comm. Expires Jan 23,2021
Signature:
-------- _------ ------ ------- --------- ---------- OPTIONAL ----- ----- ------- --------------- -------. --------
Though this section is optional, completing this information can deter alteration of the document or fraudulent
attachment of this form to an unintended document.
Description of Attached Document
Title or Type of Document:�a "'C___Document Date: 071 1 -C'
NumberofPages: 4 Signer(s) Other -Than Named Above;
Capacity(les) Claimed by Signer(s)
Signers Name: `jj �k (1,m,i �-
Q Corporate Officer -Titles)
Q Partner - Q Limited Q General
,,lndlvldual QAttorney in Fact
® Trustee QGuardian or Conservator
Q Other:
Signer is Representing:
Signers Name:
Q Corporate Officer -Titles)
Q Partner - Q Limited Q General
Q individual QAttorney in Fact
Q Trustee QGuardian or Conservator
Q other:
Signer is Representing:
_ � �}� r+ � �E _ �, IAS • t _ td�I a
_ ; r�! il ''I��_
A notary public or other officer compietingthis cert! fica e verifies only the identity of the individual who
.Signed the document, to which this certificate is attached, and notthe truthfulness, accuracy, or validity of
that document.
STATE OF CALIFORNIA
}
COUNTY OF �;k? T A A LIL}
On . 01 X04 kC beforeme, R6L(.Q '?-s'tKL-vn PQ�ja Notary
Dote I insert Dame and Title of the officer
Public, personally appeared A",4 o N 9' C LEE
Name() of Signer() .
who proved to me on the basis of satisfactory evidence to be the person(f) whose name(p) is/q e
subscribed to the within instrument and acknowledged to me that he%ah-e�tMy executed the same in
his/4&r/their authorized capacity(les•, and that by his/hpWheir signature(sj- on the instrument the
person.(s' orthe entity upon behalfofvuhich the person(sr 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.
WITNESS my hand and official seal. 6ALAI«ISHNA PFDADA
s ... NotaryPublic- California
z c Santa Clara County n
,.
Commission # 2181101
N1y Comm. Expires Jan 23,2021
Signature:
OPTIONAL----- ._..-------------------------- ....___..____
Though this section is optional, completing this information can deter alteration of the document or fraudulent
attachment ofthisform to an unintended document.
I
Description of Attached Document��1�
Title or Type of Document-. 'zq CLQ -,4a -<A - Q--Q�Document Date:
NumberofPages: Signer(s) Other Than Named Above:
Capacity(ies) Clai led by Signer(s)
5ifnem Name:
11 Corporate Ofi:icerJritle(s)
Q Partner - ❑ Limited D General
ndlvidual DAttorney in Fact
13 Trustee QGuardian or Conservator
® Other:
Signer is Representing:
Signers Name:
Q Corporate Officer -Titles)
0 Partner •- ❑ Limited 0 General
11 individual ClAttorney in Fact
El Trustee 13Guardian or Conservator
CI other,
Signer is Representing:
,?
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 Santa Clara
On IV y , 2.� 9 before me, Kirsten Squarcla , Notary Public,
(Here insert name and title of the officer)
personally appeared
,e", f- f` , R awe-rkca-
who proved to me on the basis of satisfactory evidence to be the person(s�whose names is are subscribed to
the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized
capacity), and that by his/4pp/their signatureXo on the instrument the personal; or the entity upon behalf of
which the person(,4- 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.
WITNESS my hand and official seal. i(IRSTEN SQUARCIA
Notary.Public . California z
9 Santa Clara County. >
Commission #2257322
JI
My Comm. EXpires Oct 4, 2022
(Notary Seal)
Signa a of Notary Public
ADDITIONAL OPTIONAL INFORMATION
INSTRUCTIONS FOR COMPLETING THIS FORM
DESCRIPTION OF THE ATTACHED DOCUMENT
(Title or description of attached document)
(Title or description of attached document continued)
Number of Pages Document Date
(Additional information)
CAPACITY CLAIMED BY THE SIGNER
❑ Individual (s)
❑ Corporate Officer
(Title)
❑ Partner(s)
❑ Attorney -in -Fact
❑ ' Trustee(s)
❑. Other
Any acknowledgment completed in California must contain verbiage exactly as .
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properly completed and attached to that document. The only exception is if a
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signer(s) personally appeared before the notary public for acknowledgment.
a Date of notarization must be the date that the signer(s) personally appeared which
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CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO: B-2018-1349
7889 BELKNAP DR CUPERTINO, CA 95014-4905 (362 08 036) J C S BUILDERS INC
SAN JOSE, CA 95124 .
OWNER'S NAME: DATE ISSUED: 11/01/2018
OWNER'S PHONE: PHONE NO: (408) 466-4711
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class B Lic. #966216
Contractor J C S BUILDERS INC Date 10/31/2019 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:
I hereby affirm REMODEL WHOLE HOUSE (13 77 SF)• ADDITION (692 SF); ADD (N)under penalty of perjury one of the following.two declarations: GARAGE (542 SF); ADD �) PORCH 135 ),SF • UPGRADE
( PANEL (200
1. I have and will maintain a certificate of consent to self-insure for Worker's AMPS); (N) TANKLESS WATER HEATER; (N) HVAC SYSTEM
Compensation, as provided for by Section 3700 of the Labor Code, for the
performance of the work for which this permit is issued.
i. 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: Valuation: $450000.00
APPLICANT CERTIFICATION
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 08 036 . 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.
Additionally, the applicant understands and will comply with all non-point WITHIN 180 DAYS OF PERMIT ISSUANCE OR
source regulations per the Cupertino Municipal Code,
/1/18 Issued by: Halev McKee
Date: 11/01/2018
OWNER-*LDERLARATION
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)
i. 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: 11/1/18
I hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVE
1. I have and will maintain a Certificate of Consent to self-insure for Worker's RINGS TO BE CLASS "A" OR BETTER
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. 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
Worker's Compensation laws of California. If, after making this certificateair contaminants as defined by the Bay Area Air Quality Management District I
of will maintain compliance with t •e u rtino Municipal Code, Chapter 9.12 and
exemption, I become subject to the Worker's Compensation provisions of the p
the Health & Safe .
Labor Code, I must forthwith comply with such provisions or this permit shall
be deemed revoked. Owner or authorized a gent: ,.
APPLICANT CERTIFICATION Date: 11/1/18
certify- that I have read this application and state that the above information is CONSTUCI ENDINGAGENCY
correct. I agree to comply with all city and county ordinances and state laws I hereby affirm that there is a0),igfiruction lending a ency r the performance
relating to building construction,. and hereby authorize representatives of this city of work's for which this permit is issued (Sec. 3097, iv ,)
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 public records.
Signature Date 11/1/18 Licensed
Professional