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B-2016-3077 • CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2016-3077 10697 CULBERTSON DR CUPERTINO,CA 95014-3554(375 36 034) ALI'S CONSTRUCTION &REMODELING INC SAN JOSE,CA 95129 OWNER'S NAME: DATE ISSUED: 10/31/2017 OWNER'S PHONE: PHONE NO:(408)441-0967 • LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: License Class B Lic.#909433 Contractor ALI'S CONSTRUCTION&REMODELING INC Date 01/31/2018 X BLDG _ELECT _PLUMB 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 DESCRIPTION: CONSTRUCT(N)SINGLE STORY SFD; 1,756 S.F.LIVING AREA;414 I hereby affirm under penalty of perjury one of the following two declarations: S.F.ATTACHED GARAGE;60 S.F.COVERED PORCH 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 • f,;erformance 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:2170 Valuation:$280000.00 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 375 36 034 R-3(Custom),R-3(Custom),U(Private Gar/Ag Bldg),U representatives of this city to enter upon the above mentioned property for (Private Gar/Ag Bldg) 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. PERMIT EXPIRES IF WORK IS NOT STARTED Additionally,the applicant understands and will comply with all non-point WITHIN 180 DAYS OF PERMIT ISSUANCE OR source regulations per the Cupertino Municipal Code,Section 9.18. • 180 DAYS FROM LAST CALLED INSPECTION. 000,500 gnature Date 10/31/2017 Issued by:Abby Ayende OWNER-BUILDER CLARATION Date: 10/31/2017 I hereby affirm that I am exempt from the Contractor's License Law for one of the • following two reasons: RE-ROOFS: 1. I,as owner of the property,or my employees with wages as their sole All roofs shall be inspected prior to ariy roofing material being installed.If a roof is compensation,will do the work,and the structure is not intended or offered for installed without first obtaining an inspection,I agree to remove all new materials for •sale(Sec.7044,Business&Professions Code) inspection. 2. I,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044,Business&Professions Code). Signature of Applicant: • Date: 10/31/2017 I hereby affirm under penalty of perjury one of the following three declarations: i. I have and will maintain a Certificate of Consent to self-insure for Worker's ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER 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 HAZARDOUS MATERIALS DISCLOSURE Section 3700 of the Labor Code,for the performance of the work for which this I have read the hazardous materials requirements under Chapter 6.95 of the permit is issued. California Health&Safety Code,Sections 25505,25533,and 25534. I will . 3. I certify that in the performance of the work for which this permit is issued,I maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the shall not employ any person in any manner so as to become subject to the Health&Safety Code,Section 25532(a)should I store or handle hazardous material. Additionally,should I use equipment or devices which emit hazardous 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,Chapter 9.12 and Labor Code,I must forthwith comply with such provisions or this permit shall the Health&Safety Code,Sections 25505,25533,and 25534. be deemed revoked. correct.I agree to comply with all city and county ordinances and state laws CONSTRUCTION L DING AGENCY relating to building construction,and hereby authorize representatives of this city I hereby affirm that there is a construction lending agency for the performance to enter upon the above mentioned property for inspection purposes. (We)agree of work's for which this permit is issued(Sec.3097,Civ C.) oto Cave indemnify and keep harmless the City of Cupertino against liabilities, . Lender's Name judgments,costs,and expenses which may accrue against said City in consequence of the granting of this permit. Additionally,the applicant understands Lender's Address and will comply with all non-point source regulations per the Cupertino Municipal 'Code,Section 9.18. ARCHITECT'S DECLARATION I understand my plans shall be used as public records. Signature Date 10/31/2017 Licensed Professional CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: rALI'S TRACTOR: PERMIT NO:B-2016-3077 10697 CULBERTSON DR CUPERTINO,CA 95014-3554(375 36 034) CONSTRUCTIONMODELING INC SAN JOSE,CA 95129 OWNER'S NAME: DATE ISSUED: 10/31/2017 PHONE NO:(408)441-0967 OWNER'S PHONE: LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: License Class B Lic.#909433 XBLDG _ELECT -PLUMB Contractor ALPS CONSTRUCTION&REMODELING INC Date 01/31/2020 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 JOB DESCRIPTION: license is in full force and effect. CONSTRUCT(N)SINGLE STORY SFD; 1,756 S.F.LNING AREA;414 I hereby affirm under penalty of perjury one of the following two declarations: S.F.ATTACHED GARAGE;60 S.F.COVERED PORCH 1. I have and will maintain a certificate of consent to self-insure for Worker's REV#1 -LANDSCAPE PLANS-ISSUED 04/22/2019 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 Section 3700 of the Labor Code,for the performance of the work for which this . Sq.Ft Floor Area:2170 Valuation:$280000.00 perlut is APPLICANT CERTIFICATION I certify that I have read this application and state that the above APN Number: Occupancy Type: information is correct.I agree to comply with all city and county ordinances 375 36 034 R-3(Custom),R-3(Custom),U(Private Gar/Ag Bldg),U and state laws relating to building construction,and hereby authorize for (Private Gar/Ag Bldg) representatives of this city to enter upon the above mentioned property 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 Cit in consequence of the granting of this permit. PERMIT EXPIRES IF WORK IS NOT STARTED Additionally,the applicant understands and will comply with all non-point WITHIN 180 DAYS OF PERMIT ISSUANCE OR source regulations per the Cu ertino Municipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION. Signature Date 04/22/2019 � Issued by:Abby A,yeride Date: 10/31/2017 OWNER-BUILDER DECLARATION 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 rooting 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) 2. I,as owner of the property,am exclusively contracting with licensed ode Signature of Applicant: contractors to construct the project(Sec.7044,Business&Professions Code). Date:04/22/2019 I hereby affirm under penalty of perjury one of the following three declarations: 1. I have and will maintain a Certificate of Consent to self-insure for Worker's ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER 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 permit is issued. Cha ter 9 12 and the maintain compliance with the Cupertino Municipal Code, p . 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 shall not employ any person in any manner so as to become subject to the material. Additionally,should I use equipment or devices which emit hazardous 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 exemptionI become subject to the Worker's Compensation provisions of the will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and p , Labor Code,I must forthwith comply with such provisions or this permit shall the Health&Safety APP Date:04/22/2019 ` I certify that I have read this application and state that the above information is QONSTRUCTION LENDING AGENCY 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 relating to building construction,and hereby authorize representatives of this city of work's for which this 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 plans shall be used as public records. Signature Date 04/22/2019 Licensed Professional NO FEE FOR RECORDING PURSUANT TO GOVERNMENT CODE SECTION 27383 When Recorded MaIlll To: City of Cupertino Community Development Department 10300 Torre Avenue Cupertino, CA 95014 24161869 Regina Aloomendras Santa. Clara County - Clerk: -.Recorder 04/22/2019 04:23 PM Titles: 1 Pages: 4 Fees:10.00 0.00 Taxes: 0 Total: 111 RIPON'�� �®®�1� Mhk � X"M 11A 11111 CALIFORNIA ALL-PURPOSE ACKNOWLEDGMENT {,' CODE § 11 89 A notary public or other officer completing this certificate verifies only the identity of the individual who signed the document to which this certificate is attached, and not the truthfulness, accuracy, or validity of thatdocument. State of Cal`fGrnia ) County ofnY ) 1 On before me, oAMW (f Date Here Insert Name anditle of the O is personally appeared Name(s) of Signer(s) who proved to me on the basis of satisfactory evidence to be the person(s) whose names) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies),, and that by his/her/theirsignature(s);on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the Instrument: certify under PENALTY OF PERJURY under the laws of the State of California that theloregoing paragraph is true and correct. J 'GRACE scHba{oT WITNESS my hand and official seal. - T`�: Plotary Public - California Z Santa Clara County Commission # 2275766 Signature Y '"F My Comm. Expires Feb 21, 2023 Signature of Notary Public Place Notary Seal Above OP77ONAL Though this section is optional, completing this information can deter alteration of the document or fraudulent reattachment of this form to an unintended document. -7 PIN �S_— 3�O�D 3t7 Description of Attached Document � � S ��� r Title or Type of Document Document te: 01�7 Number of Pages: �_ Signer(s) Other an Named Above: Capacity(ies) Claimed by Signer(s) Signer's Name: Signer's Name: ❑ Corporate Officer — Title(s): ❑ Corporate Officer — Title(s): ❑ Partner - ❑ Limited ❑ General ❑ Partner — ❑ Limited ❑-General ❑ Individual ❑ Attorneys in Fact ❑ Individual ❑ Attorney in Fact 0 Trustee ❑ Guardian or Conservator ❑ Trustee ❑ Guardian or Conservator ❑ Other: ❑ Other: Signer Is Representing: Signer Is Representing: 02014 National Notary Association ° www. National Notary.org ^ 1 -800 -US NOTARY (1-800-876-6827) Item #5907 . ,v e CALIFORNIA ALL-PURPOSE ACKNOWLEDGMENT Ci.I€_ CODE § 1189 A notary public or other officer completing this certificate verifies only the identity of the individual who signed the document to which this certificate is attached, and not the truthfulness, accuracy, or validity of that document. State of Cal'f.Qrnia County of On i/1' 2 Z, 2,(W 7 before me, Jc 1 Ddte Here Insert Name and Title of t4 dicer personally appeared Name(s) of Signer(s) who proved to me on the basis of satisfactory evidence to be the person(s) .whose narne(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies)T and that by his/her/theirsignature(s) on the instrument the person(s), or the entity upon behalf of which the person(s), acted, executed the instrument. certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and correct. GRACE SCFIMlOT WITNESS my hand and official seal. 4yE t °F T� Notary Public - California a Z w Santa Clara County n p Commission N 2275766 Signature RAFMy Comm. Expires feb.21, 2023 Signature of Notary Public Place Notary Seal Above OPTIONAi. Though this section is optional, completing this information can deter alteration of the docuanent or fraudulent reattachment of this form to an unintended document.. Description of Attaclhed Document ; ��( f-�� . ti Title or Type of Document: ' Document Date: .2-2 1 j Number of Pages: Signer(s) Other T an Named Above: Capaclty(ies) Claimed by Signer(s) Signer's Name: Signer's Name: 1771 Corporate Officer - Title(s): ❑ Corporate Officer — Title(s): ❑ Partner — ❑ Limited ❑ General ❑ Partner — ❑ Limited ❑ General ❑ Individual ❑ Attorneys in Fact ❑ Individual ❑ Attorney in Fact Trustee ❑ Guardian or Conservator ❑ Trustee ❑ Guardian or Conservator ❑ Other: ❑ Other: Signer Is Representing: Signer Is Representing: 02014 National Notary Association ° www. NationalNotary.org ^ 1 -800 -US NOTARY (1-800-876-6827) Item #5907 CALRFORNBA ALL-PURPOSE ACKNOWLEDGMENT CIVIL CODE § 1189 A notary public or other officer completing this certificate verifies only the identity of the individual who signed the document to which this certificate is attached, and not the truthfulness, accuracy, or validity of that document. State of California County of C ft6 C�arG On zn 1 % i �) before me, i—aLtVl-fn C_,Le, ( 0 9, 3.� �S Date Here Insert Name and Title of the 6fficer personally appeared 'Loll, y6L4 Name(s) of Signer(s) who proved to me on the basis of satisfactory evidence to be the person(s) whose name(s)nare subscribed to the within instrument and acknowledged to met" the she hey executed the same in his;Qr/their authorized capaci (ies), and that by hist/theire(s) on the instrument the ers n(s), or the entity upon behalf of which the ers (s) acted, executed the instrument. �' LoarW LAURENSAPUDAR Notary Public California z z. Y yo Santa Clara County n Commission: # 2247155 ,fly. Comm., Expires Jun 22, 2022 Place Notary Seal and/or Stamp Above I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and correct. WITNESS my hand and official seal. Signature XtVIA-�_7'a �___ Signature of Notary Public ,ra ria�naann Fa n Levu. u ueyuvi=ate Completing this information can deter alteration of the document or fraudulent reattachment of this form to an unintended document. Description of Attached Document Title or Type of Document: LC of CA Document Date: /" I L Number of Pages: Signer(s) Other Than Named Above: Capacity(les) Claimed by Signer(s) Signer's Name: El Corporate Officer — Title(s): ❑ Partner — ❑ Limited ❑ General ❑ Individual ❑ Attorney in Fact ❑ Trustee ❑ Guardian of Conservator ❑ Other: Signer is Representing: ©2017 National. Notary Association Signer's Name: ❑ Corporate Officer — Title(s): ❑ Partner — ❑ Limited ❑ General ❑ Individual ❑ Attorney in Fact ❑ Trustee ❑ Guardian of Conservator ❑ Other: Signer is Representing: