B-2016-2608 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2016-2608
10199 RICH-WOOD DR CUPERTINO,CA 95014-3313(369 08 041) JOHN SULLIVAN
CONSTRUCTION INC
CAMPBELL,CA 95009
OWNER'S NAME: ROBELL ALAN AND LAURIE A TRUSTEE DATE ISSUED:08/29/2016
OWNER'S PHONE:650-353-8720 PHONE NO:(408)247-2147
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class 5 Lic.#453736 ,
Contractor JOHN SULLIVAN CONSTRUCTION INC Date 07/31/2017 X BLDG —ELECT —PLUMB
_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:
I hereby affirm under penalty of perjury one of the following.two declarations: REMODEL(E).MASTER&HALL BATHS M.E.R'S(90 S.F.TOTAL)
i. 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
erformance of the work for which this permit is issued.
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:$15000.00
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 369 08 041
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 regulatio s per the Cupertino Municipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
�
4
Signature ,' ) Date 08/29/2016 Issued by:ME
` Date:08/29/2016
ONVNER-
BDEIR DECLARATION
_10
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. 1,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:08/29/2016
I hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
i. I haveand 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. 1 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
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 Co ^; a 'ons 25505,25 33,a d 25534.
Labor Code,I must forthwith comply with such provisions or this permit shall
be deemed revoked. f
Owner or authorized agen i1
APPLICANT CERTIFICATION Date:08/29/2016 K
I certify that I have read this application and state that the above information is CTION
correct.I agree to comply with all city and county ordinances and state laws i hereby affirm that there i a construction lending agency tor the p rformance
relating to building construction,and hereby authorize representatives of this city of work's for which this pe it 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.
Licensed
Signature Date 08/29/2016 professional
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO,CA 95014-3255
CUPERTINO (408)777.3228•FAX(408)777-3333• buildingCa7cupertino.org e 20
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NEW CONSTRUCTION ❑ ADDITION *ALTERATION/TI ❑ REVISION/ EFERRED ORIGINAL PERMIT#
PROJECT ADDRESS 1 ®� O , APN# b '" v T1
OWNER NAME PHON E-MAIL r
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STREET ADDRESS CITY, STATE,ZIP FAX
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CONTACT NAME PHONE ��, f E-MAIL
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STREET ADDRESS (0o n §TY STATE, ZIP FAX
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�Y „'NER ❑ OWNER-BUILDER D OWNERAGENT VCONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ENGINEER ❑ DEVELOPER ❑TENANT
CONTRACTOR NAME,7 1,v r� LICENSE NUMBER 5 LICENSE TYPE BUS.LIC# 9
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COMPANY NAME_ E-MAIFAX Lf O8,
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STRE DRESS CI STATE,ZIP PHONE
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ARCHITECT/ENGINEER NAME k 1 LICENSE NUMBER BUS.LIC#
COMPANY NAME J�l E-MAIL FAX
STREET ADDRESS Q CITY,STATE,ZIP PHONE
DESCRIPTION OF WORK nWa b "
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EXISTING USE PROPOSED USE CONSTR.TYPE 1,#STORIES
USE TYPE OCC. SQ.FT. /VALUATION($)
EXISTG NEW FLOOR DEMO TOTAL /
AREA AREA AREA NM AREA' "
BATHROOM KITCHEN OTHER
REMODEL ARnA REMODEL AREA REMODEL AREA
PORCH AREA DECK AREA TOTAL DECK/PORCH AREA GARAGE AREA: DETACH
ATTACH
#DWELLING UNITS: IS A SECOND UNIT YES SECOND STORY YES
BEINGADDED? . [3NO ADDITION? E]NO
PRE-APPLICATION ❑YES IF YES,PROVIDE COPY OF IS THE BLD YES tg TOTAL)16LUATION:
PLANNING APPL# NO PLANNING APPROVAL LETTER EICHLER HOME? [-]NO t �� 6
V o
By my signature below,I certify to each of the following: I am the property owner or authorized 4ent 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 an erify it is accurate. I agree to comply with all applicable local
ordinances and state laws.relating to b ildi c�t . thorize representatives of Cupertino to enter the above-identified property for inspection purposes.
Signature of Applicant/Agent: Date;
.
: ilMI+w.
SUPPLEMENTAL INFORMATION REQUIRED � <�H�,� t x .., h �� . BoP,NON
—New SFD or Multifamily dwellings; Apply for demolition permit for
existing building(s). Demolition permit is required prior to Issuance of building
permit for new building.
_Commercial Bldgs; Provide a completed Hazardous Ma*Arials Disclosure :o
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. `
„� is+ta 5._ '� EIWIROP7111EN`r' :HE'AITH f.
B1dgApp 2011.doc revised 06/21/11