B-2017-1196CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS:
CONTRACTOR:
PERMIT NO: B-2017-1196
19541 RICHWOOD DR CUPERTINO, CA 95014-3316 (369 06 005)
PACIFIC SURFACING
INC
FREMONT, CA 94539
OWNER'S NAME: SAAH IBRAHIM D TRUSTEE & ET AL
DATE ISSUED: 07/24/2017
OWNER'S PHONE: 650-776-6385
PHONE NO: (510) 440-9494
LICENSED CONTRACTOR'S DECLARATION
BUILDING PERMIT INFO:
License Class A. C9. C32 Lic. #657394
Contractor PACIFIC SURFACING INC Date 10/31/2018
X BLDG —ELECT _PLUMB
Mi RESIDENTIAL X 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:
VOLUNTARY EXTERIOR BARRIER REMOVAL COMPRISED OF
I hereby affirm under penalty of perjury one of the following two declarations:
ACCESSIBLE PARKING AND RELATED SIGNAGE FOR 10074 E.
t. I have and will maintain a certificate of consent to self -insure for Worker's
ESTATES DR. & 19541 RICHWOOD DRIVE
Compensation, as'piovided 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:
Valuation: $9571.00
permit is issued.
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 06 005
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 mply with all non -point
source re ulations per the 'Cupertino Munic' Code, Section 9.18.
180 DAYS FROM LAST CALLED INSPECTION.
atur Date 7/2412017
Issued by: Jasmine Archbold
MRI�UILDti�-DE�LAUOI
Date: 07/24/2017
-QW
A,
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
t. I,'asowner 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 Cade)
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: 7/24/2017
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 materialsirequirements 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
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
Worker's Compensation laws of California. If, after making this certificate of
air contaminants as defined by the Bay Area Air Quality Management District I
exemption, I become subject to the Worker's Compensation provisions of the
will maintain compliance with the Cupertino Municipal Code, Ch ter 9.12 and
the Health &Safety Code, Sections 25 , 25533, a 534.
Labor Code, I must forthwith; comply with such provisions or this permit shall
be deemed revoked.'
Ow fthc rized age
-
+APPLICANT CERTIFICATION
t " --- - Y - -
I certifythat I have read this a lication and state that the above information is
pp
'ENDING4 C�NS
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
y g g y
relating to building construction jand hereby authorize representatives of this city
of work's for which this permit is issued (Sec. 3097, Civ C.)
to enter upon the above mentionedip}operty 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 7/24/2017
Professional
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT - BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
C:UPERTIN� (408) 777-3228 • FAX (408) 777-3333 • buildiinnlg(@cupertino.org _,Zo `l- 1
I
r-1 X.... F AnnT-rrn-NT I5�1 AT TPP ATTC)M /TT lI 1 RFVTCTOM / T)FFFRRFn nRTC;THAT. PF.R MTT#
PROJECT ADDRESS 10074 E. Estates Dr. & Richwood Dr.
APN# 359-06-005
OWNERNAME
PHONE 650-776-6385
E-MAIL idsaah@gmail.com
The Saah Family Revocable Living Trust Dated 3/6/90
STREET ADDRESS 24024 Oak Knoll Circle
CITY, STATE, ZIP Los Altos Hills, -CA 94022
FAX
CONTACT NAME Ray Wolff
PHONE 510-440-9494 x10
E-MAIL rwolff@pacificsurfacing.com
sTREETADDREss 2066 Warm Springs Ct.
CITY, STATE, ZIP Fremont, CA 94539
FAX 510-440-9553
❑ OWNER ❑ OWNER -BUILDER ❑ OWNER AGENT ❑ CONTRACTOR. CK CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTORNAME
LICENSE NUMBER 657394
.LICENSE TYPE
BUS. LIC #,,25142
A,C-8,C32
COMPANY NAME Pacific Surfacing, Inc.
E-MAIL rwolff@pacificsurfacing.com
FAX 510-440-9553.
STREET ADDRESS 2066 Warm Springs Ct.
CITY, STATE, ZIP Fremont, CA 94539
PHONE ; 510-440-9494
ARCHITECT/ENGINEERNAME George Dedekian
LICENSE NUMBER C-10260
BUS. LIC# '.
COMPANY NAME George Dedekian Architect CASA
E-MAIL gdedekian@mac.com
FAX
STREET ADDRESS 7595 Hansom Drive
CITY, STATE, ZIP Oakland, CA 94605
PHONE 510-878-7886
DESCRIPTION.OF WORK Voluntary exterior barrier removal comprised of accessible parking and related signage.
EXISTINGUSE
PROPOSED USE CONSTR
TYPE
# STORIES
1
USE
TYPE
OCC. �'`
SQ.FT.
VALUATION ($)
EXISTG
NEW FLOOR
DEMO
TOTAL
a
AREA
AREA
AREA -
NET AREA
`
BATHROOM
KITCHEN
OTHER
REMODEL AREA
REMODEL AREA
REMODEL AREA
PORCH AREA .
DECK AREA
TOTAL DECK/PORCH AREA
GARAGE AREA: ❑ DETACH
ATTACH
# DWELLINGUNITS:
IS A SECOND UNIT ❑ YES
SECOND STORY [-]YES
BEING ADDED? NO
ADDITION? ❑ NO
i
PRE -APPLICATION ❑ YES IF YES, PROVIDE COPY OF
IS THE BLDG AN ❑ YES
-EKED BS'�own(ir-s,bf
r
^. TOTAL VALUATI�ON�'.
PLANNINGAPPL# ❑NO PLANNING APPROVAL LETTER
EICHLER HOME? []NO
0By
my signature below, I certify to each ofthe following: I am the property owner or authorized agent to act on the property half. I have read this
application and the information I have provided is correct. I have read the cription of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating to bui gawns I authorizSdgKesentatives of Cupertino to enter the above -id ntified p operty for inspection purposes.
Signature of Applicant/Agent: Date:
SUPPLE, RMATIO UIRED
PLAN CHECK,YPE„ . T T,r,
s r',i <, , ROUTING;SETI' ix
New SFD or Multifamily dwellings: Apply for demolition permit for
❑'BUILDINGi'LANVIEwt "
_
existing building(s). Demolition permit is required prior to issuance of building
OVER -T coUrrTER
permit for new building.
®" ExPREss
D PANNilvr�,rLANR> vlEw
Commercial Bldgs: Provide a completed Hazardous Materials Disclosure
0 STANDARD
form if any Hazardous Materials are being used as part of this project.
0; LARGE
Copy of Planning Approval Letter or Meeting with Planning prior to
Eh,
❑3-SANITAkY
submittal of Building Permit application.
MAaoR
SEWER _JSTRICT
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BldgApp 201 Ldoc revised "06/21/11