B-2016-1440CI,TY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS:
CONTRACTOR:
PERMIT NO: B-2016-1440
20150 APPLE TREE IN CUPERTINO, CA 95014-2002 (316 33 078)
(THD AT - HOME
SERVICES INC)
ATLANTA, GA 30339
OWNER'S NAME: Fred Kurtz
DATE ISSUED: 02/26/2016
OWNER'S PHONE: 408-446-5554
PHONE NO: 408-446-5554
LICENSED CONTRACTOR'S DECLARATION
BUILDING PERMIT INFO:
License ClassB.0-39, C-13, C-17 Lic. #836021
Contractor ( THD AT - HOME SERVICES INC) Date 02/26/2016
X BLDG —ELECT _ PLUMB
I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing
MECH X RESIDENTIAL _ COMMERCIAL
with Section 7000) of Division 3 of the Business & Professions Code and that my
license is in full force and effect.
JOB DESCRIPTION:
REPLACE (E) FRONT DOOR ENTRY (NO SIZE OR STRUCTURAL
I hereby affirm under penalty of perjury one of the following two declarations:
CHANGES)
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.
a., I have and will maintain Worker's Compensation Insurance, as provided for
1 by Section 3700 of the Labor Code, for the performance of the work for which
this permit is, issued.
Sq. Ft Floor Area:
Valuation: $4003.00
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
APN Number:
Occupancy Type:
ordinances and state laws relating to building construction, and hereby
316 33 078
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
PERMIT EXPIRES IF WORK IS NOT STARTED
expenses which may accrue against said City in consequence of the
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
granting of this permit. Additionally, the applicant understands and will'
comply with all non-point source regulations per the Cupertino Municipali., —
180 DAYS FROM LAST CAL SPECTION.
Code, Section 9.18.
Issued by: MEL
Signature _ -- "' Date 02/26/2016
Date: 02/26/2016
OWNER-BUT ER DE ATT
RE-ROOFS:
I hereby affirm that I am exempt from the Contractor's License Law for one of the
All roofs shall be inspected prior to any roofing material being installed. If a roof is
following two reasons:
installed without first obtaining an inspection, I agree to remove all new materials for
n. I, as owner of the property, or my employees with wages as their sole
inspection.
compensation, will do the work, and the structure is not intended or offered
for sale (Sec.7044, Business & Professions Code)
Signature "of Applicant:
2. I, as owner of the property, am exclusively contracting with licensed
Date: 02/26/2016
contractors to construct the project (Sec.7044, Business & Professions Code).
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
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
Compensation, as provided for by Section 3700 of the Labor Code, for the
HAZARDOUS MATERIALS DISCLOSURE
performance of the work for which this permit is issued.
I have read the hazardous materials requirements under Chapter 6.95 of the
2. 1 have and will maintain Worker's Compensation Insurance, as provided for
California Health & Safety Code, Sections 25505, 25533, and 25534. I will
by Section 3700 of the Labor Code, for the performance of the work for which
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
this permit is issued.
Health & Safety Code, Section 25532(a) should I store or handle hazardous
3. I certify that in the performance of the work for which this permit is issued, I
material. Additionally, should I use equipment or devices which emit hazardous
air contaminants as defined by the Bay Area Air Quality Management District I
shall not employ any person in any manner so as to become subject to the
will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and
Worker's Compensation laws of California. If, after making this certificate of
the Health & Safety Code, Sections 25505, 25533, and 25534.
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
Owned or authonze_d_"_agent: _�✓`�J�.-�
�be deemed revoked.
Date: 02/26/2016
APPLICANT CERTIFICATION
certify that I have read this application and state that the above information is
CONTR TI EN GAGENCY
I hereby affirm that there is a co ructi riding 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 red (Sec. 3097, Civ C.)
relating to building construction, and hereby authorize representatives of this city
Lender's Name
to enter upon :the above mentioned property for inspection purposes. (We) agree
Lender's Address
to save indemnify and keep harmless the City of Cupertino against liabilities,
judgments, costs, and expenses which may accrue against said City in
ARCHITECT'S DECLARATION
consequence of the granting of this permit. Additionally, the applicant
I understand my plans shall be used as public records.
understands and will comply with all non-point source regulations per the
Cupertino Municipal Code, Section 9.18.
Licensed
Professional
Signature Date 02/26/2016
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENTDEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE - CUPERTINO, CA 95014-3255
(408) 777-3228 • FAX (408) 777-3333 • buildina(d-)cupertino.org B a / c V 0
❑ NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION Pri ❑ REVISION / DEFERRED ORIGINAL PERMIT 4 V
PRO7ECTADDRESS ! --t.✓ 13'a / ! A� LA
OWNER NAME r PHONE E-MAIL
"` J 2! Hca c 5-S It
STREETADDRESS CITY, STATE;ZII' FAX
CONTACT NAME JEFF RAINEY PHONE 510-427-4260 E'MA'LJEFFREY.RAINEY@ATT.NET
STREET ADDRESS 1069' EDGEMERE LANE CITY, STATE, ZIP HAYWARD CA 94545 FAX 510-783-1041
IJ OWNER ❑..OWNER -BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ]91 CONTRACTOR. AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER. ❑. TENANT
CONTRACTOR NAME LICENSE NUMBER LICENSE TYPE BUS. LIC #
836021 B,C39,C13,C17
COMPANY NAME E-MAIL FAX THD AT HOME SERVICES 510-35.7-3750
STREET ADDRESS CITY, STATE, ZIP PHONE
2456 VERNA COURT SAN LEANDRO,CA 94577 510-877-4550
ARCHITECT/ENGINEER NAME _7LICENSE NUMBER BUS. LIC #
COMPANY NAME E-MAIL FAX
STREETADDRESS CITY, STATE, ZIP PHONE
DESCRIPTION OF WORKr
N .ni P VI_( I > ( e a I rA) '71°2 tDe9z �j - /J
EXISTINGUSE PROPOSED USE - CONSTR-TYPE #STORIES - - - -
USE TYPE OCC. SQ.FT. VALUATION ($)
EXISTG NEWFLOOR - DEMO TOTAL. •. _ - _ - - - -
AREA AREA AREA NET AREA
BATHROOM KITCHEN - OTHER--
REMODELAREA REMODELAREA REMODELAREA.
PORCH AREA. DECK AREA TOTAL DECKIPORCH AREA I GARAGE AREA: EIDETACH -
Q ATTACH
#DWELLING UNITS: IS.A SECOND UNrr ❑ YES SECOND STORY ❑YES _
BEING ADDED? r1 NO ADDTTION? -
PRE -APPLICATION ❑ YES IF YES, PROVIDE COPY OF IS..� - VALUATION:
PLANNINGAPPL# ❑NO PLANNING APPROVAL LETTER ERHOME? E] NO _ _ �. yDm�G�_.
By my signature below, I certify to each of the following: I am the property owner or ao act on the 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 auth ' epresentatives of Cupertino to r1Jie above -identified property for inspection purposes.
Signature of ApplicantJAgent:-.....���°^'"' ._„�^^Date:
17 1
SUPPLFMDA"tI IlVF:7�
TIO ATTIRED
KAM",
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_New SFD or Multifamily dwellingly for Olition permit for x
Vi: THIrCQtIYTT> R n[1>IGR&stn
existing building(s). Demolition permi red priorto issuance of building
permit for new building. Q rss l PTiE
_ Commercial Bldgs: Provide a completed Hazardous Materials Disclosure IeIIIo r
form if any Hazardous Materials are being used as part of this project
_ Copy Of Planning Approval Letter or Meeting with Planning prior to V,
submittal of Building Permit application.£ ��xNrtitExt niszr
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