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B-2016-2847 CITY OF CUPERTINO BUILDING PERMIT BUH.DINGADDRESS: CONTRACTOR: PERMIT NO:B-2016-2847 21180 GARDENA DR CUPERTINO,CA 95014-1620(326 40 017) CELTIC CONSTRUCTION SAN JOSE,CA 95125 OWNER'S NAME: CHAN WALLACE CAND HELENE W TRUSTEE DATE ISSUED:10/03/2016 OWNER'S PHONE:408.-2454522 PHONE NO:(408)973-1224 LICENSED D ONT A TOR' DECLARATION ATION BUILDING PERMIT INFO: License Class a Lic.#857916 Contractor CELTIC CONSTRUCTION Date 11/30/2016 X BLDG —ELECT X PLUMB I hereby affirm that I am licensed under the provisions of Chapter 9(commencing MEECH 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 under penalty of perjury one of the following two declarations: REPLACE(8)WINDOWS,(1)SLIDING DOOR,IST FLOOR(2)BATHROOM REMODEL M,E,P(63 SF);KITCHEN REMODEL M,E,P r. I have and will maintain a certificate of consent to self-insure for Worker's (165)SF); Compensation,as provided for by Section 3700 of the Labor Code,for the REPLACE 50 GAL WATER HEATER-OUTSIDE UTILITY CLOSET performance of the work for which this permit is issued. r 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 Floor Area: Valuation:$65000.00 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 326 40 017 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 reg to per the upertino Municipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION. Signature I/ Date 10-3-2016 Issued by:Kim Dunbar Date: 10/03/2016 OWNER-B iii.D RD . LARATION I hereby affirm that I am exempt from the Contractor's License Law for one of the RFS—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(Sce.7044,Business&Professions Code). Date:10-3-2016 I hereby affirm under penalty of perjury one of the following three declarations; ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER 1. 1 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 the 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 material. Additionally,should I use equipment or devices which emit hazardous shall not employ any person in any manner so as to become subject to the I 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 C tino Municipal Code,Chapter 9.12 and exemption,I become subject to the Worker's Compensation provisions of the the Health&Safety C e,S tions 25505, 5533,and 25534. Labor Code,I must forthwith comply with such provisions or this permit shall be deemed revoked. Q__Owner or authorized agent r� — APPLICANT CERTIFICATION Date:10-3-2016 I 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. 1 understand my plans shall be used as public records. Signature Date 10-3-2016 Licensed Professional CONSTRUCTION PERMIT APPLICATION t COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 10300 TORRE AVENUE• CUPERTINO,CA 95014-3255 (408)777-3228•FAX(408)777-3333• buildin cuoertino.or +G UPERTIt�lC2 NM-V CONSTRUCTION ❑ ADDITION ❑ ALTERATION/`TI ❑ REVISION/'DEFERRED_ ;ORIGINAL PERMIT# PROJECT ADDRESS APN n OWNER NS_r PHONE A1 E-MAIL STREET ADDRESS.fiCITY,STATE;ZIP FAX t 3�& A L T CONTACT NAME PHONE E-MAIL k STREETADDRESSCITY,STATE,LIP FAX �3 ON°NER ,I� O-WNER-BALDER. ❑ OVNTTERAGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER 0 TENANT CONTRA N LICENSE ER LICE' TYPE BU L COirNAV EMG,AILE FAX b d Y, g T�g, io Sfi / \a�✓ ��F TY,STATE:ZIP (rt �i 0 ARCIIITECT/ENOIN,EER NAI`IE LICENSE NUMBER BUS.LIC r COtiR'ANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE Iy CRIPTIO. OF WORK f! levva& 41 EXISTING USE PROPOSED USE CONSTK TYPE ,STORIES USE TYPE OCC. SQ.FT. VALUATION AREANFwFLOOR DLNIO.—�� TOTAL - -- AREA AREA AREA NET AREA BATHROOM KITCHEN 'OTHER REMODEL AREA REN40DELAREA REMODEL AREA_.--u�"= PORCH AREA DECKAREA - �TOTAL DECKIPORCH AREA GARAGE AREA: ❑DETACH ❑ATTACH DwELLIN'G UNITS: ISA SECOND UNIT ❑YES ,SECOND STORY ❑YES _ BEL\G ADDED? ❑NO ADDITION? ❑NO PFE-APP/'CATION ❑YES IF YES;PROVIDE COPY OF 1S THE BLDG AN ❑YES RE EDs TOTAL VALliATIO�': PLAhfi�C.AP.PL= ❑NO PLANNING APPROVAL LETTER � EICHLER HOME? E]NO y; xc ",._ "�"�./�� By my signature below,1 certify to each of the following: I am the property owner or authorize 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 constriction.. I authorizze^represe,3tatives of upertino to enter the abovef�identified property for inspection purposes. Signature of Applicant/Agent: ( � fo l Date: SUPPLE/IENTAL INFORMATION REQUIRED LAT CH PECKTIPE I20UTING New SFD or Multifamily dwellings: Apply for demolition permit for Cp a\ER THE cauNTERPLS.R1 S IE��}� existing buildmg(s). Demolition permit is required prior to issuance of building � .PLA 4I�ING PLAM1 REQ IE1 permit for new building, 1-�,,EaPR>ss _commercial B1dQs:-Provide a completed Hazardous Materials DisclosuID re STANZ)ARD C� PUBLIC i oRl.s form if any Hazardous.Materials are being used as part of this project. LARGE ,FIRE DEPT _Copy Of Planning Approval Letter or Meeting with PIanring prior to [� AL9�oR []'SAhrTARY SEZ4ERDISTRICT submittal of Building-Pennit application. ? -1 w y r ENS�I 6NiiIENTAI HEALTI3;. B1dgApp 2011.doc revised 061211111