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B-2016-3010 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2016-3010 10470 PINEVILLE AVE CUPERTINO,CA 95014-4523(369 13 035) FUTURE VISION REMODELING INC VAN NUYS,CA 91406 OWNER'S NAME: GORGEN GARYAAND IRIS M TRUSTEE DATE ISSUED:10/31/2016 OWNER'S PHONE:408-252-8659 PHONE NO:(800)485-4919 LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: License Class GENERAL BUILDING CONTRACTOR Lic.#991840 Contractor FUTURE VISION REMODELING INC Date 04/30/2018 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: 1ST FLOOR BATHROOM REMODEL-45(S.F.) I hereby affirm under penalty of perjury one of the following two declarations: 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 t;_performance of the work for which this permit is issued. I have and will maintain Worker's Compensation Insurance,as provided for by y 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 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 369 13 035 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 C pertino Municipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION, i C Sg ature / Date 10/31/2016 Issued by:AbbyAyende Date: 10/31/2016 OWNER-VII 1 I i ECLARATION 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:10/31/2016 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 the s. 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 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:10/31/2016 I certify that I have read this application and state that the above information is CO 'UC elENDINGAGENCY 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 10/31/2016 Licensed 9 Professional %-201.(i - ro CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT BUILDING DIVISIONry,_7.,:tir,..„, 11111 10300 TORRE AVENUE• CUPERTINO,CA 95014-3255 r (408)777-3228• FAX(408)777-3333• buildino cuDerfino,orq CUPERTINO' ❑NEW CONSTRUCTION ❑ ADDITION ❑ALTERATION/TI ❑ REVISION/DEFERRED ORIGINAL PERMIT PROJECT.ADDRESS.( 6 0470 pi w\e. 41 APNr teci 15- 0 OWNER P.NAME V /� < PHONE E-*LAIC �i tO,`—e J.-7-i ' Y t ', r STREET:ADDRESS Co' Y - U.@ CITY,STATE.ZIP FAX t,, t41, P ev\\e �! > t;- ,'io. � c 9saliit CONTACT.=ME • ); P121' H{yn�� _�4j/ „A_ v V f g 1 1 i E-_\L^Z STREET ADDRESS CITY,STATE,ZIP FAX D OWNER 0 OW,R-BUILDER 0 OA'_M.AG' 0 CONTRACTOR 0 CONTRACTOR AGENT 0 ARCHITECT 0 ENOEC 2 0 DEVELOPER 0 TENANT • I ' CONTRACTOR NAME(� LICENSE NUMBER LICENS'-TYPE BUS.LIC r • �l'vi-F�tl'e V:SAO YI aid 1E Lf 0 —CSS � �( "WAXY NAME r_F.TL r `„f FAX 4tRre �` St�3rt ' ottc1-)'hA-Evit2'viiovit�'i 04etf4L .com CITY�;STATE,ZTkPHONE TADDRESS =it Y� iWn• Cow 2\ C `_EiO 7 - Lth- 4 I 9'BUS.LIC Aal RCctI"i TEC<TII EER CME ?IC SH NUMBER COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE -- DESCRIPTION OF WORK & , \Ali C�C C r�C c `:e'_ _ry a ,, `ri_kCp,> ' `?'l1 IN V\e EXISTBIG USE PROPOSED USE CONSTR.IPE _STORIES USE TYPE OC SQ.FT. VALUATIO (5) EXISTG CCR FLOOR DE„0 TOTAL li AREA AREA AREA NET AREA I'I BATHROOM KITCHEN OTHER RE ODEL AREA REMODEL AREA REMODEL AREA PORCH ...REA DECK AREA F TOTAL DECKPORCH ARIA GARAGE AREA: ❑DETACH ❑ATTACH DWELLING UNITS: ISASECONDLWIT ❑IES SECOND STORY DYES - -- BELK'G ADDED? ❑NO .ADDITION? D:0 ISI PRE PPLICATIDN IT YES IF IES PROVHIE COPY OF IS THE BLDG AN' 0 YES EiVED$� r TOT.. ..VALUATION: PL.AOc GADPL' 0N PLA\',L'�G.PPROV.ALLe1!ER EICHLERHOME? DN0 .-r fi r 1 �'� ��?��,.. . .I 1 `til By my signature below,I certify to each of the following: I am the property owner or authorized agent to ac on the prope y 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 b ']ding slc;-. . I authorize representatives of Cupertino to enter the a.+ve-idfnti d propel y for inspection purposes. Signature of Applicant/Agent:_- Dat i ft SUPPLEMENT.--_ .' c ATI01\I REQUIRED PLA_\ iihd>:T1PEg. „, r _.;.as:ROLTINGSLIP_:; x x New SFD orlt uILlf rTIly dtseihngs Apply for demolition permit for s mac. OI ER TI E COL-\TER- BL0;kV:PLA-\RES'TECi existing.bu1Jo1110(s). Demolition.pen t IS rnoui eo prior li issuance it or.,.E�Q p ei l,t for new building. EIPRESS E PL�.'t\L\GPLA_\REt IE\1 -. Commercial BIdgc Prot ide a completed Hzzardou_?tiatenplsDi_clesure STAND RD1.i:iit - i °L'BLIC WORKS r-i 1I any i- zarooL__tipt.-.rials _ form `, is T i are oe1nQ ed az rd i s this p:OjeCt. - c ❑ r !RGE I] FIRE DEPT Copy of Planning Approval Letter or Meeting with Planning prior to K fl LAJOR SA tITARl SEZ�ERD!�TRICT submittal OI Bi]11OIn�'Permit application. ,�tiallt - .: �, -- NiAlitw,::.�. .. , _..,> <, ENIIRON-M1IE\'TA L HE4LTIi -: Bldgt'pp_2011.doc revised 06/21/11