B-2018-1295 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2018-1295
20821 SCOFIELD DR CUPERTINO,CA 95014-2922(359 12 006) RESIDENTIAL
CONSTRUCTION
SERVICES
SAN JOSE,CA 95124
OWNER'S NAME: DATE ISSUED: 11/28/2018
OWNER'S PHONE: PHONE NO:(408).981-9778
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class B Lic.#546684
Contractor RESIDENTIAL CONSTRUCTION SERVICES Date 11/30/2020 X BLDG _.ELECT —PLUMB
I hereby affirm that I am licensed under the provisions of Chapter 9(commencing X 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:
FIRST FLOOR ADDITION(6 10 SF);COVERED PORCH(28 SF);(N)
I hereby affirm under penalty of perjury one of the following two declarations: FURNACE/AC IN ATTIC FOR ADDITION;INTERIOR REMODEL(70
I have and will maintain a certificate of consent to self-insure for Worker's SF)TO RELOCATE WASHER DRYER TO GARAGE AND REMOVE
Compensation,as provided for by Section 3700 of the Labor Code,for the BATH#1 TO CREATE PANTRY.
performance of the work for which this permit is issued. REV#1 -CHANGE THE MODEL OF THE FIREPLACE-ISSUED
I have and will maintain Worker's Compensation Insurance,as provided for by 5/30/19
Section 3700 of the Labor Code,for the performance of the work for which this REV#2-CHANGE POSITION OF FIREPLACE-ISSUED 5/30/19
permit is issued.
APPLICANT CERTIFICATION Sq.Ft Floor Area:610 Valuation:$235000.00
1 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 359 12 006 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,co acid expenses which
may accrue against said City iconsequence o e c ranting of this permit. PERMIT EXPIRES IF WORK IS NOT STARTED
Additionally,the applicant unrstan. and w' o ply with all non-point WITHIN 180 DAYS OF PERMIT ISSUANCE OR
source Section 9.18.
180 DAYS FROM LAST CALLED INSPECTION.
Signature - Date 5/30/19 Issued by: McKee
y v
Date: 11/28/2018
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)
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:5/30/19
I hereby affirm under penalty of perjury one of the following three declarations:
1. I have and will maintain a Certificate of Consent to self-insure for Worker's ALL ROOF COVERINGS 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 h �ardous
shall not employ any person in any manner so as to become subject to the material. Additionally,should I use equipment or devices which a ,� hazardous
Worker's Compensation laws of California. If,after making this certificate of air contaminants as defined by the Bay Area AiQua!'y Manag 'ent District I
exemption,I become subject to the Worker's Compensation provisions of the will maintain compliance with the
25534.
be deemed revoked.
APPLICANT CERTIFICATION
Owner or authorized agent:
Date:5/30/19
I certify that I have read this application and state that the above information is CONSTRUCTION L NDING 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 public records.
Signature---- Lia ed
Professional
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO: B-2018-1295
20821 SCOFIELD DR CUPERTINO, CA 95014-2922 (359 12 006) RESIDENTIAL
CONSTRUCTION
SERVICES
SAN JOSE, CA 95124
OWNER'S NAME: DATE ISSUED: 11/28/2018
OWNER'S PHONE: PHONE NO: (408) 981-9778
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
_License Class B Lic. #546684
__- X BLDG _ ELECT _ PLUMB
Contractor RESIDENTIAL CONSTRUCTION. SERVICES Date _11/30/2020
X 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:
FIRST FLOOR ADDITION (6 10 SF); COVERED PORCH (28 SF); (N)
I hereby affirm under penalty of perjury one of the following two declarations: FURNACE/AC IN ATTIC FOR ADDITION; INTERIOR REMODEL (70
1. I have and will maintain a certificate of consent to self-insure for Worker's SF) TO RELOCATE WASHER DRYER TO GARAGE AND REMOVE
WiCompensation, as provided for by Section 3700 of the Labor Code, for the BATH #1 TO CREATE PANTRY.
performance of the work for which this permit is issued.
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: 610 Valuation: $235000.00
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 359 Number: Occupancy Type:
3
and state laws relating to building construction, and hereby authorize 59 12 006 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 th granfiing of this permit. WITHIN 180 DAYS OF PERMIT ISSUANCE OR
Additionally, the applicant unde ands and will mply with all non-point
source regulations the C rtino Code, Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
Signature Date 11/28/18 Issued by: Haley McKee
Date: 11/28/2018
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: 11/28/18
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
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 Nazar
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 z dous
Worker's Compensation laws of California. If, after making this certificate of air contaminants as defined by the Bay Area Air Quality Ma ee strict I
will maintain compliance with the Cupertino MuAicipal e., t 9.12 and
exemption, I become subject to the Worker's Compensation provisions of the the Health & Safety Co Sections 4.
Labor Code, I must forthwith comply with such provisions or this permit shall
be deemed revoked. Owner or authorized age •
APPLICANT CERTIFICATION Date: 11/28/18
I certify that I have read this application and state that the above information is C=ONSTRUCTION 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. 1 understand my plans shall be used as public records.
Signature Date 11/28/18 Licensed
Professional