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B-2017-0388CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: CONTRACTOR: PERMIT NO: B-2017-0388 948 BROOKGROVE IN CUPERTINO, CA 95014-4668 (375 39 03 1) R W CONSTRUCTION CO SAN JOSE, CA 95129 OWNER'S NAME: CHEN CHRISTINE HAND TEOTIA NEERAJ P DATE ISSUED: 03/09/2017 OWNER'S PHONE: 408-805-2847 PHONE NO: (408) 206-6139 LICENSED CONTRACTOR'S DECLARRATION BUILDING PERMIT INFO: License Class B Lic. #407021 Contractor R W CONSTRUGTION CO Date 06/30/2018 X BLDG X ELECT _ PLUB M 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 DESCRII'TION: 1 st FLOOR BATHROOM REMODEL (52 SF) PANEL UPGRADE (200 I hereby affirm under penalty of perjury one of the following two declarations: AMP) 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. 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 Sq. Ft Floor Area: Valuations $12000.00 permit is issued. APPLICANT CERTIFICATION I certify that 1 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 375 39 031 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 Cupertino Municipal Code, Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION. Signature/ Date 3-9-2017 Issued by: Kim Dunbar OWNER-BUILDER DECLARATION Date: 03/09/2017 I hereby affirm that I am exempt from the Contractor's License Law for one of the RE-ROOFS: All roofs shall be inspected prior to any roofing material being installed. If a roof is following two reasons: 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: X2017 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. 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 maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the permit is issued. 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 material. Additionally, should I use equipment or devices which emit hazardous shall not employ any person in any manner so as to become subject to the 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, Sec ' ns 25T505,25533, 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: 3-9-2017 f I certify that I have read this application and state that the above information is CON ICTION E AGENCY I hereby affirm that there is a construction lending agency for the performance correct. I agree to comply with all city and county ordinances and state laws of work's for which this permit is issued (Sec. 3097, Civ C.) relating to building construction, and hereby authorize representatives of this city 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, Lender's Address judgments, costs, and expenses which may accrue against said City in consequence of the granting of this permit. Additionally, the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal T'a DECLARATION AR be used I understand my plans shal1l1 be used as public records. Code, Section 9.18. Licensed Signature Date 3-9-2017 Professional CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 ERTtN9 (408) 777-3228 . FAX (408) 777-3333 • building(c)cupertino.org j �_ II `6 C�UP � II I- NEW C ONSTRIICTIC)N I f�I 1 AT)T)TTToN 1 AT ATTnM / TT I I RF�7TCT(1T.T / TIRRRnu Rr� nDMUNTAT DVDA41T 4F PROJECT ADDRESS r APN # A / ✓ CJC� U e Gr OWNER NAME/ / ,veeval PHONE E-MAIL STREET ADDRESS pp / L& CITY, STATE, ZIP �— , F 0 t- Y i�P V? � G ✓ l f. CONTACT NAMET - HONE E-MAIL STREET ADDRESSCITY, Zvi- ll STATE, ZIP FAX 2 ocd :� K - 2122-9 ❑ OWNER ❑ OwNERBuiLDER ❑ OWNERAGENT CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME p i e",7- �.:: , LICENSE NUMBER . 0 D 2 TLICENSE TYPE BUS. LIC # b 3 Lj�j COMPANY NAME q� (A) 7-- E- L FAX STREET ADDRESS CITY, STATE, ZIP C 20 C Vt! GJ © A — 121 ARCHITECTIENGINEERNAME LICENSE NUMBER BUS. LIC# COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,. STATE, ZIP PHONE DESCRIPTION OF WORK _ % 9 % 00 r 6 Li! ftii lJ6 e 3X T15 3. ie? o '10" 3 9f- r�>�� 1 it 7 ,� EXISTING USE PROPOSED USE CONSTR TYPE # STO S - I USE TYPE OCC. SQ.FT. VALUATION ($) EXISTG NEW FLOOR DEMO TOTAL AREA AREA AREA NET AREA BATHROOM KITCHEN OTHER REMODEL AREA REMODEL AREA REMODEL AREA PORCH AREA DECK AREA TOTAL DECK/PORCH AREA GARAGE AREA: EIDETACH t ❑ ATTACH I # DWELLING UNITS: ISA SECOND UNIT ❑ YES SECOND STORY E] YES BEING ADDED? [.NO ADDITION? ❑NO PRE -APPLICATION ❑ YES IF YES, PROVIDE COPY OF IS THE BLDG AN ❑ YES TOT LX LUf l PLANNING APPL # ❑ NO PLANNING APPROVAL LETTER EICHLER HOME? ❑ NO Z*ED dal By my signature below, I certify to each ofthe following: I am the property owner or authorized�agent to act on the property owner's behalf. I havefead 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 onstructio . I authorize representatives of Cupertino to enter the above-i�derntifie property for inspection purposes. Signature of Applicant/Agen Datel,-3 Aq SUPPLEMENTAL INFORMAAG& REQUIRED PLAN CHECK TYPE ROUTING SLIP' ❑ OVER-THE-COUNTER ❑ BUILDING PLAN REVIEW _ New SFD or Multifamily dwellings: Apply for demolition permit for existing building(s). Demolition permit is required prior to issuance ofbuilding permit for new building. ❑ EXPRESS ❑ PLANNING PLAN REVIEW Commercial Bldgs: Provide a completed Hazardous Materials Disclosure ❑ STANDARD ❑ PuBLic woxxs form if any Hazardous Materials are being used as part of this project. ❑ LARGE ❑. FIRE DEPT _ Copy of Planning Approval Letter or Meeting with Planning prior to El MAJOR El SANITARY SEWER DISTRICT submittal of Building Permit application. ❑ ENVIRONMENTAL HEALTH BldgApp_2011.doc revised 06/21/11