B-2016-3147n
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS;
CONTRACTOR:
PERMIT NO: B-2016-3147
10675 S DE ANZA BLVD STE 4 CUPERTINO, CA 9501411449 (359 23 033)
ALLEN B SHAG
FREMONT, CA 94539
OWNER'S NAME: SEAGRAVES WALTER M II ET AL
DATE ISSUED: 01/17/2017
OWNER'S PHONE: 408-768-0668
PHONE NO: (510) 557-7622
LICENCED CONTRACTOR'S DECLARATION
BUILDING PERMIT INFO:
License Class 13 Lic. #845496
Contractor ALLEN B SHAO Date 08/31/2018
X BLDG —ELECT —PLUMB
I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing
MECH _ RESIDENTIAL X COMMERCIAL
with Section 7000) of Division 3 of the Business & Professions Code and that my
license is in full force and effect.
JOB DESCRIPTION:
TO CLEAR CODE ENFORCEMENT CASE: UNIT 4; T.I. - REMODEL
I hereb affirm under penalty of perjury one of the following two declarations:
BATHROOM (63 S.F.); REMOVE 1 WALL - YES SCHOOL,
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.
,�',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: $5000.00
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
359 23 033
A (Tenant hnprovements),A (Tenant hnprovements),A
representatives of this city to enter upon the above mentioned property for
(Tenant Improvements),A (Tenant Improvements),A
inspection purposes. (We) agree to save indemnify and keep harmless the
(Tenant Improvements),A (Tenant Improvements),A
City of Cupertino against liabilities, judgments, costs, and expenses which
(Tenant Improvements),A(Tenant Improvements),A
may accrue against said City in consequence of the granting of this permit.
(Tenant Improvements),A (Tenant Improvements),A
Additionally, the applicant understands and will comply with all non -point
(Tenant Improvements)
source regulations per the Cupertino Municipal Code, Section 9.18.
—
PERMIT EXPIRES IF WORK IS NOT STARTED
Signature_r'� --Date 02/14/2017 .
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
OWNER-BUIIDER DECLARATION
180 DAYS/FRA' CALLED INSPECTION.
I hereby affirm that I am exempt from the Contractor's License Law for one of the
following two reasons:
Issued by;
r. I, as owner of the property, or my employees with wages as their sole
Date:
compensation, will do the work, and the structure is not intended or offered for
sale (Sec.7044, Business & Professions Code)
RE -ROOFS:
2. I, as owner of the property, am exclusively contracting with licensed
All roofs shall be inspected prior to any roofing material being installed. If a roof is
contractors to construct the project (Sec.7044, Business & Professions Code).
installed without first obtaining an inspection; I agree to remove all new materials for
I hereby affirm under penalty of perjury one of the following three declarations:
inspection.
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
Signature of Applicant:
performance of the work for which this permit is issued.
Date: 02/14/2017
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
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
permit is issued.
3. I certify that in the performance of the work for which this permit is issued, I
HAZARDOUS MATERIALS DISCLOSURE
shall not employ any person in any manner so as to become subject to the
I have read the hazardous materials requirements under Chapter 6.95 of the
Worker's Compensation laws of California. If, after making this certificate of
California Health & Safety Code, Sections 25505, 25533, and 25534. I will.
exemption, I become subject to the Worker's Compensation provisions of the
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
Labor Code, I must forthwith comply with such provisions or this permit shall
Health & Safety Code, Section 25532(x) should I store or handle hazardous
be deemed revoked.
material. Additionally, should I use equipment or devices which emit hazardous
air contaminants as defined by the Bay Area Air Quality Management District I
APPLICANT CERTIFICATION
will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and
I certify that I have read this application and state that the above information is
the Health & Safety Code, Sections 25505, 25533, and 25534.
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
1
Owner or authorized agent> /, "---_--- -L ---
to enter upon the above mentioned property for inspection purposes. (We) agree
_ _
Date: 02/14/2017
to save indemnify and keep harmless the City of Cupertino against liabilities,
L.
judgments, costs, and expenses which may accrue against said City in
consequence of the granting of this permit. Additionally, the applicant understands
CONSTRUCTION NDIN . AGENCY
I hereby affirm that there is a construction lending agency for the performance
and will comply with all non -point source regulations per the Cupertino Municipal
of work's for which this permit is issued (Sec. 3097, Civ C.)
Code, Section 9.18.
Lender's Name
Lender's Address
Signature Date 02/14/2017
ARC'HITECT'S DECLARATION
I understand my plans shall be used as public records.
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
CUPERTINO (408) 777-3228 • FAX( (408) 777-3333 • building cCDcupertlno.org
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DESCRIPTION OF WORK
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#DWELLINGUNITS:
IS ASECOND T1Nrr YES
SECOND STORY ❑YES
BEENGADDED7 NO
ADDITION? NO
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PRH -APPLICATION E] YES IF YES, PROVIDE COPY OF
PLANNING APPL9 ❑NO PLANNENGAPPROVALLETTER
ISTULBLDCAN ❑YES
RICHLERITOMR2 [3 NO
:REIVED.BY"_-`-"-:ii:.
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By my signature below, I certify to each of the following: I am the propetiy owner or authorized agent to act on i 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 building construction. I authorize representatives of Cupertino to enter the above -identified property for inspection purposes.
Signature ofApplicant/Agent: _ '$ Date: tR - f d f
SUPPLEMENTAL INFORMATION.._:.=.:_=
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— New SFD or Multifamily dwellings: Apply for demolition permit for
existin buildin (s). Demolition emit is required prior to issuance of buildnl
_OVER'-THI:rCOUNC1\:at.:;;,';-::,'[
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permit for new building.
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Commercial Bldgs: Provide acompleted Hazardous Materials Disclosure
&--in if ally Hazardous Materials are being used as part ofthis project.
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Copy of Planning Approval Letter or Meeting With Planning prior to
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