B-2016-3275CITY OF CUPERTINO BUILDING P
RMIT
BUILDING ADDRESS:
CONTRACTOR:
PERMIT NO: B-2016-3275
10164 POTTERS HATCH CMN CUPERTINO, CA 95014-2655 (342 35 043)
FUTURE VISION
REMODELING INC
VAN NUYS, CA 9140
OWNER'S NAME: KOLESOV VICTOR AND KOLESOVA VICTORIA
DATE ISSUED: 12/14/2016
OWNER`S PHONE: 408-250-3354
PHONE NO: (800) 485-4919
LICENSED ONT A TOR' DECLARATION
BUILDING PERMIT
INFO:
License Class B Lic. #991840
Contractor FUTURE VISION REMODELING INC Date 04/30/2018
X BLDG _ ELECT
PLUMB
I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing
_ MECH X RESIDENTIAL
T COMMERCIAL
with Section 7000) of Division 3 of the Business & Professions Code and that my
license is in full force and effect.
JOB DESCRIPTION:
2ND FLOOR MAS
ER BEDROOM BATHROOM (23 S.F.)
I hereby affirm under penalty of perjury one of the following two declarations:
Re1PA06
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.
z.) 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: $3000.00
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
342 35 043
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 E3
PIRES IF WORK IS NOT STARTED
may accrue against said City in consequence of the granting of this permit.
Additionally, the applicant understands and will comply with all non -point
WITHIN 18
DAYS OF PERMIT ISSUANCE OR
source regulations per upertino Municipal Code, Section 9.18.
180 DAYS F
OM LAST CALLED INSPECTION.
Signature Date 12/14/2016
Issued by: A A
mde
OWNER -BUILDER DECLARATION
Date: 12/14/2016
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 insl
ected 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)
z. 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: 12/14/2016
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.
2. I have and will maintain Worker's Compensation Insurance, as provided for by
I have read the haz
ardbus 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 C
3de, 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. Addition
air contaminants as defined
y, should I use equipment or devices which emit hazardous
by the Bay Area Air Quality Management District I
Worker's Compensation laws of California. If, after making this certificate of
will maintain compli
Luce 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 2 S, X5533, and 25534.
Labor Code, I must forthwith comply with such provisions or this permit shall
be deemed revoked. <
Owner or authorize
agent:
APPLICANT CERTIFICATION "
Date: 12/14/2016
certify that I have read this application and state that the above information is
-CONSTRUCTION
I hereby affirm that tt
LENDING AGENCY
iere is a construction lending agency for the performance
correct. I agree to comply with all city and county ordinances and state laws
relating to building construction, and hereby authorize representatives of this city
of work's for which tt
is 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 plar
is shall be used as public records.
Licensed
Signature Date 12/14/2016
Professional
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT -BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228 • FAX (408) 777-3333 • building(&-cupertino.org
❑ NEW CONSTRUCTION ❑ ADDITION ® ALTERATION / TI ❑ REVISION / DEFERRED ORIGINAL PERMIT #
PROJECT ADDRESS o. 6 3-G�4('G, ��-C CEJ /' APN # 3421
OWNER NAME /� ,,}� ,+L� /��J Q / ` C_- �•ii�j ? ,�/
�( C. 'l.� o � J�C/ le_5 o V PHONE . 00) 7_5® -JJ 7 &MAII -
STREET ADDRESS CITY, STATE, ZIP FAX
CONTACT NAME 1-P, e PHONE �u>�� E-MAIL
STREET ADDRESS ` CITY, STATE, IPJ FAX
ZI
❑ OWNER. ❑ OWNER -BUILDER OWNER AGENT .CONTRACTOR ❑
CONtT{RACTORAVG1�ENTr 101 CHITECT El ENGINEER 1:11 I DEVELOPER
EVELOPER
1:1 TENANT
CONTRACTOR NAME LICENSE NUMBER NSE TYPE BUS.LIC#U7
N,
COMPANY NAME E-MAIL "IuCte6FAX
STREET ADDRESS 1919 4 1�qS C C f_ � K CITY, STATE, ZZIPP cctmj e l l f C I q 30 �j� PHONE (J a �iJJp� -qq pI
ARCHITECT/ENGINEERNAME vet LICENSE NUMBER t BUS.LICC#' `l!! t
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY, STATE, ZIP PHONE
TYPE I OCC.
VALUATION ($)
property owner's behalf. I have read this
ate. I agree to comply with all applicable local
,e -identified property for inspection purposes.
1 Iu 1(6
B1dgApp 201'1.doc revised 06121111
i
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DESCRIPTION OF WORK
C P (are
ff �14�
1 [ (
j(� t /y�e
5 /_ _ pr Nv,/
yL�J Y
f
EXISTG
NEW FLOOR
r
TOTAL
AREA
AREA
AREA
NET AREA
BATHROOM
KTTCHEN
TYPE I OCC.
VALUATION ($)
property owner's behalf. I have read this
ate. I agree to comply with all applicable local
,e -identified property for inspection purposes.
1 Iu 1(6
B1dgApp 201'1.doc revised 06121111
i
I
USE
EXISTG
NEW FLOOR
DEMO
TOTAL
AREA
AREA
AREA
NET AREA
BATHROOM
KTTCHEN
OTHER.
REMODEL AREA J� j' /r°15
REMODEL AREA
REMODEL AREA
PORCH AREA DECK AREA -
TOTAL DECKIPORCH AREA
GARAGE AREA: DETACH
_
❑ ATTACH
#DWELLING UNITS:
IS A SECOND UNIT ❑YES
SECONDSTORY ❑YES
BEING ADDED? [-]NO
ADDITION? ❑ NO
PRE_APPLICATION ❑ YESIF YES, PROVIDE COPY OF
IS THE BLDG AN ❑ YES
; R - rvED,BY,
PLANNING ADPL# Fl NO PLANNING APPROVAL LETTER
EICHLERHOME? NO
i
By my signature below, I certify to each of the following: I am the property owner or authorized agent to ct
application and the information I have provided is correc have read the Description of Work and verify it is
ordinances and state laws relating to building c,, representatives of Cupertino to enter th
/uthorize
Signature of Applicant/Agent: Date: _
SUPPLEMENTAL INFORMATION REQUIRED
PLAN CM
El OYER THE=C
New SFD or Multifamily dwellings: Apply for demolition permit for
existing building(s). Demolition permit is required prior to issuance of building
permit for new building.
--'EXPRESS `
Commercial Bldgs: Provide a completed Hazardous Materials Disclosure
) sTAND,8
form if any Hazardous Materials are being used as part of this project.
TARGE ', 4
_ Copy of Planning Approval Letter- or Meeting with Planning prior to
MAJOR - ` '
submittal of Building Permit application,
,
TYPE I OCC.
VALUATION ($)
property owner's behalf. I have read this
ate. I agree to comply with all applicable local
,e -identified property for inspection purposes.
1 Iu 1(6
B1dgApp 201'1.doc revised 06121111
i
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