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B-2018-0176CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: CONTRACTOR: PERMIT NO: B-2018-0176 10101 N DE ANZA SWI] CUPERTINO, CA 95014 (326 34 071) HOLDER CONSTRUCTION GROUP LX ATLANTA, GA 30339 OWNER'S NAME: WATERDRAGON 289 LLC OWNER'S PHONE: LICENSED CONTRACTOR'S DECLARATION License Class B Lic. #9779&3 Contractor HOLDER CONSTRUCTION GROUP LLC Date 10/3112018 I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of Division 3 ofthe Business & Professions Code and that my license is In full force and effect. I hereby affirm under penalty of perjury one of the following two declarations: 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. I have and will maintain Worker's Compensation Insurance, as provided for by vSection 3700 of the Labor Code, for the performance of the work for which this 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 and state laws relating to building construction, and hereby authorize 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 may accrue against said City in consequence of the granting of this permit. Add€tionally, the applicant understands and will comply with all non -point source regulations pel the Cupertino NfuniG1pal Code, Section 9.1 13, Signature Date 04_/29/2018 I hereby affirm that I ani exempt from the Contractor's License Law for one of the ving two reasons: 1. 1, as owner of the property, or my employees with wages as their sole compensation, will do the work, and the structure is not intended or offered for sale (Sec.7044, Business & Professions Code) 2. 1, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec,7044, Business & Professions Code) I hereby affirm under penalty of perjury one of the following three declarations: i, 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. 1 have and will inaintain 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. 3, 1 certify that in the performance of the work for which this penuit is issued, I shall not employ any person in any manner so as to become sub)ect to the Worker's Compensation laws of California. If, after making this certificate of exemption, I become subject to the. Worker's Compensation provisions of the Labor Code, I must forthwith comply with such provisions or this permit shall be deemed revoked. 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 and state laws relating to building construction, and hereby authorize representatfves 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 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 Code, Section 9.18. Date 01!2912018 DATE ISSUED: 01/29/2018 PHONE NO: (770) 958-3000 BUILDING PERMIT INFO: X BLDG —ELECT —PLUMB ME CH _ RESIDENTIAL X COMMERCIAL JOB DESCRIPTION: APPLE T.LPREP 4TH STORY - (12000 SF) Ft Floor Arca: l Valuation: $550090.00 APN Number: Occupancy Type: 32634071 PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 1.80 DAYS FROM LAST CALLED INSPECTION, Issued by: Jasmine Archbold Date: 01129/2018 RE -ROOFS: All tcofs shall be inspected prior to any roofing material being installed. If a roof is installed without first obtaining an inspection, I agree to remove all new materials for inspection. Signature ofApplicant: Date: 01/29/2018 ALL ROOF COVERINGS TO BE CLASS "A" HAZARDOUS MATERIALS DISCLOSURE I have read the hazardous materials requirements under Chapter 6,95 of the California Health & Safety Code, Sections 25505, 25533, and 25534. 1 will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Section 25532(x) should 1 store or handle hazardous material. Additionally, should I use equipment or devices which emit hazardous air contaminants as defined by the Say Area Air Quality Management District I will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Sect ns 2 05, 25533, an S Owner or authorized agent: Date: 01/29/2018 CONSTRUCTION L 1 NDtNG AGENCY I hereby affirm that there is a construction lending agency for the performance of work's for which this permit is Issued (Sec. 3097, Civ C.) Lender's Name Lender's Address ARCHPI'EC'1'°S DECLARATION I understand my plans shall be used as public records, Licensed Professic CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT - BUILDING DIVISION 10300 TORRE AVENUE a CUPERTINO, CA 95014-3255 (408) 777-3228 - building@cupertino.org PEMIT #B --2-C) I - CVPERTINO - REV# DEF# ❑ NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION ®T•I. ❑ ivi T ❑ RE -ROOF ❑ SWIMMING POOL/SPA PROJECT ADDRESSD -PNP 1 a fv, 31 s `to t �L/ a�� OWNER PI]ONE E-MAIL STREETA SS CITY, STATE, ZIP, NT M,eoNTRACTOR NAME ❑ O NER-BUILDER LICENSE NUMBER LICENSE TYPE �COMFANYNAMR H01hU- to ts4rudio,n 1?1�q 63 STREET ADDRESS 4�5 6w4-ewa i!/&a t"'Je 3.w CITY, STATE, ZIP 5a,^ ')ese.'GA 15d o E-MAIL r / e PHONE BITS. LIC P 'CnW �tr� h.. e:, 3 j © ARCHITECT Q OWNER ❑ OWNER AGENT © CONTRACTOR AGENT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CONTACT NAME } E -MAUL STREET ADDRESS CITY, STATE, ZIP PHONE ;?6 as we,/4ce S4; 32r7 .soh.. Jose" 100 So DESCRIPTDN /fly ..l e- 1 X2.,< /Cl/o/ SIVA � �t ;CA^ f �j Z6 t.Gl Ge. -W;/( :),/�f � nat, r 46 -[6&tv ❑SINGLE-FAMILYIDUPLEX []MULTI -FAMILY ❑ INDUSTRIAL WCOMMERCIAL USE TYPE OCC '$Q.PT. VALUATION ($} RXIS7G USE EXISTING SF NEW FLQQR 5F PQRCI-I SF DHCK SF DEtvlO SF STORIES C TOTAL NET SF REMODEL REMODEL KITCHEN REMODEL OTHR GARAGE ❑ ATTACHED - BATHROOM 5F SF SF SF ❑ DETACHED RXISING ❑ YES FIRE SPRINKLERS 0 NO EICHLER Ll YES ❑ NO SECON13STORY ADDITION ❑ YES ❑ NO DWELLING SECOND DWELLING ❑ YES ❑ ATTACHED ❑ DETACHED OTHER UNITS: UNITADDT170M El No SR POOLS1 ❑ FIBERGLAS 1TED POOL - SF SPA - sl ` r� � `B TOTAL - SF ` r/+ R CEIVEi] I3Y: TAL VALUATION: ComnisreiaiOrmullf-PaniflyPrOf �EnvlraauierrYnlHeatHnupri+val s QS�oOr��d rJ RE -ROOF EXISTING ROO:t �/ 1GLES❑ WOOD SHAKES ❑ WOOD SHINGLES ❑TILE OTHER (SPECIFY) REMOVE /REPLACE ❑ NO :13181, PLYWOOD TYPE; PITCH: �Z ROOF CLASS ❑ YES �] +r i r f 7IHER ❑ O5B ❑ CDX OTHER A, PROPOSED ROOF TYPE: 0131) v D SHAKES ❑ WOOD SI [INGLES ❑ OTHER *Provide a signed copy o f SF Pof sQUAR1;5 20 �� V By nay signature below I he property owner or authorized agent to act on the property owner's behalf. I have read this applicatio: .s correct. I have read the Description of Work and verify it is accurate. I agree to comply with all apph aws relating to building construction. l authorize representatives of Cupertino to - enter the above -identified Nruperty for inspectio ses. I ackno Q e and authorize all information captained on this application form to be made available for public record. o Signature of Applicant/Agent: Dater SUPPLEMENTAL INFORMATION REQUIRE *Nmv SFD/Second Dwelling Units/Multifamily Dwellings! A Demolition permit is required prior to issuance of a building permit for all nets construction, *Commercial Buildings: Provide a completed Hazardous Materials Disclosure form if any Hazardous Materials are being used as part of this project. *Copy of Planning Approval Letter or Meeting with Planning prior to submittal of Building Permit application. "HOA -Provide a letter of approval from the Home Owner's Association BldgApp_2017.doc revised 08101117