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B-2017-0066 CITY OF CUPERTINO BUILDING PERMIT BUlIDINGADDRESS: CONTRACTOR: PERMIT NO:B-2017-0066 21552 REGNANT RD CUPERTINO,CA 95014-4819(356 23 039) PRUDHON BUILDERS SCOTTS VALLEY,CA 95066 OWNER'S NAME: GEE RICHARD E AND KIMBERLY H DATE ISSUED:01/12/2017 OWNER'S PHONE:408-398-3963 PHONE NO:(408)390-7251 LICENSED D ONT A TOR'S DECLARATION BUILDING PERMIT INFO: License Class B Lic.#776376 Contractor PRODHON BUILDERS Date 03/31/2018 X BLDG —ELECT _PLUMB MECH X RESIDENTIALCOMMERCIAL I hereby affirm ithat 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 fulli'force and effect. JOB DESCRIPTION: KITCHEN REMODEL-M,E,P(150 SF);REMODEL 1st FLOOR I hereby affirm„ander penalty of perjury one of the following two declarations: BATHROOMS(2)-M,E,P(80 SF) 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 perfoimance 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 permit is issued. Sq.Ft Floor Area: Valuation:$50000.00 APPLICANT CERTIFICATION (I certify that I h'2ve 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 356 23 039 representativesl 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 unde lands and will comply with all non-point source regulations per the Cue ino Municipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION. r "Signature Date 1112/2017 Issued by:AbbyA3=de Date:01/12/2017 OWNER-B 1TI:DER DECLARATION I hereby affirm'ifhat 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 r. 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. 1,as owner of the property,am exclusively contracting with licensed Signature ofApplicant: contractors to construct the project(Sec.7044,Business&Professions Code). Date:1/12/2017 I hereby affirm',under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A”OR BETTER 1. I havel 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 perfb inane 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 s. 1 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 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 Munici ode,Chapter 9.12 and exemption,I become subject to the Worker's Compensation provisions of the the Health&Safety Code,See' ns 2550 ,2 33,and 25534. Labor'Code,I must forthwith comply with such provisions or this permit shall be deemed revoked. Own r or authorized agent: _ iy APPLICANT CERTIFICATION Date:1/12/2017 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,cos is,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. Licensed Signature Date 1/12/241_7 Professional 4, CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO,CA 95014-3255 (408)777-3228•FAX(408)777-3333•build ing(aDcupertino.org j O'NEW CONSTRUCTION ❑ ADDITION ALTERATION!Ti ❑ REVISION/DEFERRED ORIGINAL PERMIT# PROJECT ADDRESS: APN# OWNERNAME,� �'yG� 0 2 3q(8 E-MATT, STREET ADDRESSCITY, STATE,ZIP FAX l t k�a( C,l -vim t 1,0 G - 4 JO/u ®--a�--- CONTACT NAMEPHONEE-MAo v-u c o� �t� ) 3 Qo - a 5_1� IL��, c,� �� r � 1��I�Pmt� ccs, STREET ADDRESS CITY,STAT ,ZIP FAX ajCrl Cl e �c{v� VJai �Y �7C0 41,C El OWNER OWNER-BUILDER ❑ OWNER AGENT CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTORNAME � !� LICEN NUMBER L`CENSETYPF, � BUS.LI �� _2C�v ?Tu VlC�vl .� COMPANYNAN,IE (� �pe E-MAIL (I ( p �! t` [ii ev5 Cl 1 LCL i/S. ��17ri F STREET ADDRESS730-7 5, 1L)owevircc CITY,STATE,ZIP PHO 2�2-5/ ARCFHTECT/M ER NAME LICENSE NUMBER BUS. C# COMPANY NAME E-MAIL FAX 'I STREET ADDRESS CITY,STATE,ZIP PHONE DESCRIPTION OF WORKV �C M012ege-4- Leo la c e k-t' c-b e GtJ e,(,e All cc-(t t 1>)E'it> pCCO—ItA ✓L Crt7)eiPJ 0 �I& GVIt-P1 ^- i' EXISTING USE 1 PROPOSED USE CONSTR TYPE #STORIES USE TYPE OCC. SQ.FT. VALUATION($) EXISTG j` NEW FLOOR DEMO TOTAL AREA 1' AREA AREA NET AREA BATHROOM KITCHEN OTHER REMODEL ARES REMODEL AREA REMODEL AREA PORCH AREA DECK AREA TOTAL DECK/PORCH AREA GARAGE AREA: El DETACH ❑ATTACH #DWELLING UNITS: IS A SECOND UNIT ❑YES SECOND STORY ❑YES BEING ADDED? ❑NO ADDITION? ❑NO PRE-APPLICATION ❑YES IF YES,PROVIDE COPY OF IS THE BLDG AN ❑YES RECEIV D BY VALUATI�O�N: PLANNING APPL# ❑NO PLANNING APPROVAL LETTER EICHLER HOME? [-]NO (IMIA WWI- iqaD By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on e 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 build i constructrn. I au e presentatives of Cupertino to enter the above-identified property for inspection purposes. Signature of Oplicant/Agent: Date: �/ Op j, SUPPLEMENTAL INFORMATION REQUIRED PLAN CHECK TYPE ROUTING SLIP _New SED or Multifamily dwellings: Apply for demolition permit for C1 OVER-THE-COUNTER: ❑ BUILDING PLAN REVIEW" existing buil'ding(s). Demolition permit is required prior to issuance of building permit for neiw building. ❑ EXPRESS © "PLANNING PLAN REVIEW I r. __Commercial Bldgs: Provide a completed Hazardous Materials Disclosure 171STANDARD El PUBLICWORKS T if any Hazardous Materials are being used as part of this project. 1] LARGE ElFIREDEPT - Copy of planning Approval Letter or Meeting with Planning prior to ❑ MAJOR ❑ SANITARY SEWER DISTRICT submittal ofiBuilding Permit application. ❑ ENVIRONNIENTALHEALTH BldgApp_2011.doc revised 06121/11 I i