B-2019-0023 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2019-0023
1145 STEEPLECHASE LN CUPERTINO,CA 95014-5816(359 31 05 1) JOHN MASON
CONSTRUCTION
WATSONVILLE,CA
95076
OWNER'S NAME: Yusem Stuart I DATE ISSUED:01/04/2019
OWNER'S PHONE:408-857-5830 PHONE NO:(831)320-2261
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class B Lic.#987402
Contractor JOHN MASON CONSTRUCTION Date 10/31/2019 X BLDG —ELECT X 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:
REMODEL(2)BATHROOMS
I hereby affirm under penalty of perjury one of the following two declarations: REV#1 -RECONFIGURE BATHROOM LAYOUT-ISSUED 01/08/2019
1. I have and will maintain a certificate of consent to self-insure for Worker's REV#2-REMOVE AND REPLACE EXISTING SEWER LINE FROM
Compensation,as provided for by Section 3700 of the Labor Code,for the UNDER HOUSE TO SIDEWALK(2)CLEAN-OUTS-ISSUED 1/29/2019
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 thep erformance of the work for which this
permit is issued. Sq.Ft Floor Area: Valuation:$17000.00
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 APN Number: Occupancy Type:
and state laws relating to building construction,and hereby authorize 359 31 OS l
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 01/29/2019 Issued by:Haley McKee
Date:01/04/2019
OWNER-BUILDER DECLARATION
1 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:01/29/2019
1 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. 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 pen-nit 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:01/29/2019
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.
Signature Date 01/29/2019 Licensed
Professional
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT * BUILDING DIVISION
10300 TORRE AVENUE e CUPERTINO, CA 95014-3255 B
(408) 777-3228 * buildingCoPcuperfino,org PERMIT#B q 3
C V P E RT I N 0, 1 REV# DEF#
❑ NEW CONSTRUCTION ❑ADDITION ❑ALTERATION El T.I. [:1 MEP ❑RE-ROOF ❑ SWIMMING POOL/SPA
PROJECT ADDRESS APN 9 C)
OWNER NAME PHONE E-MAIL
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STREET ADDRESS r CITY, STATE,ZIP
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-ErCONTRACTOR NAME [:1 OWNER-BUILDER COMPANY NAME LICENSE NUMBER LICENSE TYPE
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STREET ADDRESS CITY,STATE, ZIP
E-MAIL PHONE BUS.LIC
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El ARCHI`FE& [:1 OWNER Me5WNER AGENT ❑CONTRACTOR AGENT❑ENGINEER❑DEVELOPER❑TENANT
CONTACT NAME E-MAIL
STREET ADDRESS CITY,STATE,ZIP PHONE
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SINGLE-FAMILY/DUPLEX ❑MULTI-FAMILY [:1 INDUSTRIAL El COMMERCIAL
EXISTING USE EXISTING SF NEW FLOOR SF PORCH SF DECK SF DEMO SF STORIES# TOTAL NET SF USE TYPE OCC SQ.FT. VALUATION
REMODEL REMODEL KITCHEN REMODEL OTHR GARAGE ❑ATTACHED
BATHROOM SF SF SF ST ❑DETACHED
EXISING [1 YES EICHLER El YES SECOND STORY ADDITION []YES
FIRE SPRINKLERS[:1 NO [:] NO El NO
DWELLING SECOND DWELLING El YES []ATTACHED El DETACHED OTHER
UNITS# UNIT ADDITON: ONO S F
POOLS
� []F
IBERGLASS []VINYL-LINED []GUNITE ❑PREFABRICATED
POOL-SF SPA-SF_ 7 SPA ATTACHED El YES [I NO TOTAL-SF E,'CEIVE I D BY: TOTAL VALUATION:
Commercial or Multi-Fainifil Buildings with Public Swimming Pools requires DLTartment of Environmental Heath approval
RE-ROOF1 EXISTING ROOF TYPE: [--]BUILT-UP ROOF[]ASPHALT SHINGLES[—]WOOD SHAKES[—]WOOD SHINGLES E]TILE OTHER(SPECIFY)
REMOVE/REPLACE[]NO IF NO PLYWOOD El'/2�" E]3/8" PLYWOOD TYPE: PITCH: ROOF CLASS
E]YES #OF LAYERS THICKNESS❑5/8" OTHER [—I OSB [—]CDX OTHER —:12 A
PROPOSED ROOF TYPE:EIBUILT-UP ROOF EIASPHALT SHINGLES DWOOD SHAKES E]WOOD SHINGLES DOTHER
*Provide a signed copy of the Cupertino's Tear-Off Policy SF #of SQUARES
By my signature below I certify to each of the following: I am the property owner or authorized agent to act on the property owner's behalf. I
have read this application and the information I have provided is correct. I have read the Description of Work and verify it is accurate. I agree
to comply with all applicable local ordinances and state laws relating to building construction. I authorize representatives of Cupertino to
enter the above-identified property for inspection purposes. I acknowledge and authorize all information contained on this application form
to be made available for public 415�.
recor
Signature of Applicant/.Agent:."_2�: 1
Date:
SUPPLEMENTAL INFORMAfGON REQUIRED
*New SFD/Second Dwelling Units/Multifamily Dwellings:A Demolition permit is required prior to issuance of a building permit for all new construction.
*Commercial Buildings: Provide a completed Hazardous Materials Disclosure form if any Hazardous Materials are being used as part of this project.
*Copy of Planning Approval Letter or Meeting with Planning prior to submittal of Building Permit application.
*HOA-Provide a letter of approval from the Home Owner's Association
BldgApp-2017.doc revised 08101117