Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
B-2016-2329
CITY OF CUPERTINO BUILDING PERMIT DUILDINGADDRESS: STEVENS CREEK BLVD CUPERTINO, CA 95014 (3'16 20 112) CONTRACTOR: OWNER PERMIT NO: B-2016-2329 -13U LDER OWNER'S NAME:tAWUr �8y �!}� ry}yT§�\ 19 9 . Ax i' i B� DATE ISSUED: 07/21/2016 . OWNER'S PHONE: 408-896-6601 " PHONE NO: BUILDING PERMIT INFO: LICENSED CW17RACIMS DF I ARATION . License Class Lie. # Contractor OWNEF2-B� Date X BLDG _ ELECT X PLUMB. II hereby affirm that I am licensed under the provisions. of .Chapter 9 (commencing. — MCH— RESIDENTIAL X COMMERCIAL with Section 7806) of Division 3 of the Business & Professions Code and that my license is in full force and effect. JOB DESCRIPTION: I hereby affirm under penalty of perjury one ofthe following two dedarations: BETWEEN SHOP 3 & SHOP 4; INSTALL (I) DESIGNATED GAS LINE 1. 1 have and will maintain a certificate of consent to self -insure for Worker's FOR OPEN FIRE PIT Compensation, as provided for by Section 3700 ofthe Labor Code, forthe performance ofthe. 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 permit is issued. Sq.FtFloorArea: Valuation: $2000.0.0 APPLICANT CERTIFI ATION 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 and state laws relating to building .construction, and hereby authorize 316 20' 112 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 ofthe granting of this permit. 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. Signature Date 7/21/2016 Issued'by: AbbyAyende Date: 07/21/2016 OWNER-BL1iI.DERDECLARATION I hereby affirm that I am exempt from the Contractor's License Law for one ofthe RE -ROOFS: following two reasons: All roofs shall: be inspected prior to any roofing material being installed. If'a roof is 1. 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 (S 7044, Business & Professions Code) f as owner oftheproperty, am exclusively contracting v, th licensed Signature of Applicant: contractors to construct the project (Sec.7044, Business & Professions Code). Date: 7/21/2016 I hereby affirm under penalty of perjury one ofthe following three declarations:: i. I have and will maintain a Certificate of Consent to self -insure for Worker's ALL ROOF COVERINGS.T[3 BE CLASS "A'° OR BETTER Compensation, as provided for by Section 3700 of the Labor Code, for the performance ofthe work for which this permit is issued. HAZARDOUS MATERIALS DISCLOSURE I 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 cif the Labor Code, for the performance ofthe work for which this California Health & Safety Code, Sections 25505, 25533, and 25534. I will permit is issued. maintain compliance �eith;the Cupertino Municipal Code, Chapter 9.12 and the 3. 1 certify that in the performance ofthe 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 air contaminants 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 Cnpertu►0 Muni fpal Code, Chapter 9.12 and p exemption, I become subject to the Worker's Compensation provisionsofthe the. Health & Safety Code, Sections , 25533, and 25534. Labor Code, I must forthwith comply with such provisions or this permit shall be deemed revoked. APPLICANT CERTIFICATION (lbate: Os er or authorized. agent: , 7/21/2016 I certify that I have read this application and state that the. above information is CONSTRUCTION LENDING AGENCY. correct. t 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 wich this permit is issued: (Sec. 3097, Civ C.) to enter upon the above mentioned property for inspection purposes. (We) agree Lenders 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 ARCHITECT'S DECLARATION and will. comply with. all non -point source regulations per the Cupertino Municipal Code, Section 9.18. 1 understand my plans shall be used as public records. Sig ture Date 7121/2016 Professional CUPERTINO I WRWYYINSTRTic.Tim CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION; 10300 TORRE AVENUE . CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 • building@cugert'ino.ora ^ f3 � zor� �. 2•.3 - AT7nITTOM I I AT.TRRT ATT0M/TI I 1 PP.VTCVIN/nPRRT2RT;.TI nQT/;T-.T-r z? PROJECT ADI?RESSf [� ��j APN # RWNERNAME .... HONaa"CF-MAIL q J/0 (kAA U te' A r•d s STREETADDRESS CITY, 5 ATE,ZIP l F A�Co� ?zS D3'7U CONTACT NAME YL�X / J 1� �j U PA� t ( r SIRE T DESS 1' I I CITY,. Ain, ZIP < FAX '7ZS� 637 v ❑ OWNER OWNER-BUILDPR ❑ OWNERAGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME ` UCENSENUMBER LICENSETYPE BUS. LIC COMPANY NAME E-MAIL FAX - STREET ADDRESS CITY, STATE, ZIP PHONE ARCI:TITECTIENGINEERNAME LICENSE NUMBER BUS. LIC# COMPANYNAME E-MAIL FAX STREETADDRBSS CITY, STATE, ZIP PHOi�E DESCRIP•1'IONOFWORK EXISTING USE PROPOSED USE CONSTR TYPE 11 STORIES USE. TYPE OCC. 5Q.FT. - - VALUATION EXISTG NEWFLOOR DEMO TOTAL AREA AREA AREA NETAREA - BATHROOM - KITCHEN - OTHER _ - REMODELAREA ItEMODF,LAREA RFMODELAREA PORCH AREA DECK AREA TOTALDECKIPORCH AREA GARAOE AREA: ❑ DETACH I I [] ATTACH I #DWELLINGUNITS: ISASECONDUNIT ❑YES SECONDSTORY ❑YES__ BEING ADDED? []NO ADDITION? PRE -APPLICATION ©YES IF YES,PROVIDE COPY OF IS THE IILD .;-ICECELY0TAL. VAL�lA TION: PLANNINGAPPLB FINO PLANNING APPROVAL LETTER EICHLERHOME? ❑NO '•�' By my signature below, I certify to each of the fallowing: I am the property owner or authori-r. agent to t T the property owner's behalf, l have read this application and the information I haveprovided is COIR ct. ve read the Description of work an verify it is accurate: agree to comply with all applicable local ordinances and state laws relating to b nstt i I utlnori ]a�tatives of G�Ipertino to enter the ab`o7ve-' el reed properly for inspection purposes. t l SignatureofApplicant/Agent: Date: t97/' SUPPLEMENTAL INFORMATION Q i?•._'-,,,PLANGHECi{,TYPE„ --..=.=5 :_i =. __:ROUTIRG$LIP.•.._;, _:-.:• _,-:_ ❑` OVER TlIE COUNT L1' ❑ BUILIIING PLAN RE\ lE\l _ Lit for �l for demolition ecu New SFD or Multifamily dwellings: Apply p existing building(S). Demolition permit is required prior to issuance of building ' "_ - permit for new building. :._❑,:EX.PRESS �__PL�A1VtmGTLANRI✓1IEN _ Commercial Bldgs: Provide a completed Hazardous Materials Disclosure _.< :5 STANDAhI5 ❑ rdeuc wo xxs To—rin if any Hazardous Materials are being used as part of this project. ❑' LARGE `: __ ; , ;, ,:, . t0 :FIRE DEPT, , ', Copy of Planning Approval Letter or Meeting with Planning prior to • ❑ \'L1JOR ;:_ ; ❑ SAIQIT iRY 5ER ER DIS1'1tTCT submittal of Building Permit application. _;...;.... , ?rENVIRONI4ENTALHI?AhTH-`v;:[' B1dgApp 2011.doe revised 06121111 10 M CL;PERTI N NEw C®NSTRUC:TInN I CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING: DIVISION 10300 TORRE AVENUE - CUPERTINO, CA 95014-3255 (408) 777-3228 FAX (408) 777-3333 • buildfn2 cupertlno om .AT)nmynm A T mon A TT— r PROd$CI ADDRESS{ta, APN #OWNERXAMB j .^ F 7 IIN+T fJ Qs f, PHONE p l .j� 7 3 0 E.IM j / [. �'rd l�f� 4krt STREETADDRFSS CITY,. TE,ZIP l CONTACT NAME r PHOVUl'0 (}l( &-n k1w, , V �1f l� lJ S Aj.a y cT 7 FAX 7 0 0, OWNER OWNER-BUJI01I; I -I OWNERAGENT I CONTRACTOR I� CONTRACTORAGENT CI ARCMTLCT Q ENGWM ® DEVELoPIR 0 TENANT NTItACTORNAME 7' � w LICENSE NUMBER IICENSETYf'E BUS. LIC# MPANYNAME ICOSTRERTADDRIISS E-MAIL rAX CITY, STATE, ZIP PHONE ARCUITECTIENGINEFR NAME LICENSE BUS. LIC# COh4PhNYNAMA -NUMBER EMAIL pA7C STREET ADDRESS CITY, STATE, ZIP PHONE DFSCRIP'I'ION OF WORK 01 E7fISTD44 USE PROPOSED USE CONSTR.7 YrH # STOREES USE TYPE OCC. SQ.FT. VALUATION (P E)USTG' NEWTI.ODR DEMO TOTAL - - - - ABPA .AREA AREA ,NATAREA BATHROOM .. - KITCHEid.- ..REMOPELAREA REMODELAREA REMOPI'IMARBA PORCH AREA. -DECKAREA - 76TALDECKlPORCHARSA GARAOEAREA: 'DETACH -- - --- [] ATTACH #DWSUINOUNITS: T3A$ECONDUNIT []YES SECO1jDSTORY [3YEs - I3EINGADDEDY . ONO ADDITION? PRE -APPLICATION DYES IFYE%PROVIPECOPY OF ISTHRBLD. - , TOTAL-VON: PLANNINGAPPLB ❑RIO PLANNING APPROVAL LETTER EICELERHOME7 NO By my signature below, I certify to each of the following: I aim the properly owner or authoriz agent to t i the property owner's behalf. I have read this application and the information I have provided is coir at. ve. read t7xe TDesetiption of Work aIi verify it is ate;/1 agree to comply with all applicable local ordinances and state lavas relating to b ' 'u nstt uthorize _ pPes tafiueS of CTlpettino to eiiteP the sh'o7ve ' c1T ' ljed Irropeliy far iihspection purposes. SignatureofAppiieantlAgent: SUPPLEMENTAL INFORMATION REQiJMM :..:...:.:.::::..:.::: :•_:?=;:rEnlicl�cl�:TYr>...:--. :_..,....:_.,..;:.._...: _.....;..;:. -.�°_-°>--:_�oTrr>xcSDIP�:.... ... -- OVKi�T(;SCOUJV[kl� _ New SFD or Multifamily dwellings: Apply for demolition permit for existing buildin s, I3elnolitiorT erinitvs.r aired. riortoissuancoaYfliuildirl permit for new building, ❑ )sXPi2hSS•, ^ ....... .__ ..._ 4-.PLAhe\[AG7LAIaRC4IEhY Commercial Bldgs: Provide a completed Hazardous Materials Disclosure : � srAhDD�,zhD ❑ Pua� i� ivoRlcs forin if any Hazardous Materials are being used as part oft is project _'Copy of Planning Approval Letter or AiLeetrng with Planningprior to :-� D7A.FQR CI SAit`iTARX SEiYER Di&'IItiCT submittal of Building Peednit application.. _. .CI.-:HN��i1ON\4SiV`TAI•., R1dgAPP 2(111.doc revised 06121111 1J OWNER -BUILDER DISCLOSURE FORM COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE - CUPERTINO, CA 950143255 i l F'BRTiN[C (408) 777-3228 FAX (408) 777-3333 building(ftuperlino.o'ra Dear Property Owner(s): An application for a building .permit has been submitted in your name listing yourself as the builder of the property improvements specified at; We are providing you with an Owner -Builder Acknowledgment and Information Verification Form- to make you aware of your responsibilities and possible risk you may incur by having this permit issued in your name. as the Owner -Builder. We will. not issue a building permit until you have read, initialed your understanding .of each provision, signed, and returned this form to .us at our offl iai address: indicated. An agent of the owner cannot execute this notice unless you, the property owner; obtain the prior approval of the permittirig authority. OWNER'S ACKNOWLEDG41VIENT AND VERIFICATION OF INFORMATION (DIRECTIONS. Please reed and'%nitiaf each statement below to signify you understand or verify this information.) 1.J understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner- Bui dein building permit that erroneously implies that the property owner is providing his or her own labor and material. personally. 1, as an Owner -Builder, may be held liable and subject to serious financial risk for any injuries sustained by an unlicensed person and his or her employees while working on my property. My :homeowner's insurance may not provide coverage for those injuries. I am willfully acting as an Owner -Builder and am aware of the limits of my insurance coverage for injuries to workers on my property. � 2. l understand building permits are not required to be signed by property owners unless they are responsible for theconstruction and are not hiring a licensed Contractor to assume this responsibility. 3. I understand as an "Owner -Builder" lam the responsible party of record on the permit. l understand that I may pr tect myself from potential financial risk by hiring a licensed Contractor and having the permit flied in his or her name,instead of my own. k4. I understand Contractors are required by law to be licensed and bonded in California and to list their license numbers on permits and contracts. Ail 5:1 understand if I :employ or otherwise engage any persons, other than California licensed Contractors, and the total value of my construction is at least five hundred dollars: ($500), including labor and materials„ I. may be considered an "employer" under state and federal law. A-6- I understand if I am considered an "employer' under state and. federal law, I must register with the state and federal government, withhold payroll taxes, provide workers'. compensation disability insurance, and contribute to unemployment compensation for each `employee" I also understand my failure to abide by these laws may subject me to serious financial risk. 7. I understand under California Contractors' State. License Law, at! Owner -Builder who builds single-family residential structures cannot legally build them with the intent to offer them for sale, unless all work is performed by licensed subcontractors. and the number of structures does not exceed four within any calendar year, or all of the work is performed under contract with a licensed general building Contractor. 8. I understand as an Owner -Builder if I sell the property for which this permit is issued, t may be held liable for an financial or personal injuries sustained by any subsequent owner(s) that result from any latent construction defects in the workmanship or materials. OwnerBuilderForm 2010.doc reWsed 04114110 9. I understand I may obtain more -information regarding my obligations as an 'employer" from the Internal Revenue Service,. the United States ' Small Business Administration the California Department of Benefit Payments, yments, and the California Division of Industrial Accidents. I also understandI may contact the California Contractors' State License Board (CSLB) at 1-800-321 -CSLB (2752.) or www.esib.ca.gov for more information about licensed ctors. 0, 1 am aware of and consent to an Owner -Builder building permit applied for ini my name, and understand that I am the party legally and financially responsible for proposed construction activity, at the site address listed above. 011. I agree that, as the party legally and financially responsible for this proposed construction activity, I will abide by all applicable laws and requirements that govern Owner -Builders as well as employers. qL12. I agree to notify tify the issuer of this form' immediately of any additions, deletions, or changes to any of the information I have provided on this form. Licensed contractors are regulated by laws designed to protect the public. If you contract with someone who does not have a license, the Contractors' State License Board may be unable to assist you with any financial loss you may sustain as a result of a complaint. Your only remedy against unlicensed Contractors may be in civil court. It is also important for you to understand that if an unlicensed Contractor or employee of that individual or firm is injured while working onyour property, you may be held liable for damages. If - you obtain a permit as Owner -Builder and wish to hire Contractors, you will be :responsible for verifying whether or not . insurance coverage. those Contractors are properly licensed and the status of their workers' compensation CONSTRUCTION, LENDING AGENCY (DIRECTIONS: Please complete the following construction lending agency information.) I 'hereby affirm that there is -a construction lending agency for the .performance of the work for which this permit is issued (See 3097 Civ.) Lender Name: Lender Address: Before a building permit can be issued, this form must be completed and signed by the property owner and returned to the agency responsible for issuing the permit. Note: A copy of the property owner's driver's license, form notarization, or other verification acceptable t the city may be required to be presented when th erilt is issued to vefifv the Dronertv ownnr:q qi6natilrIZA h 1 / \ r � e/P I I Property Owner's Signature: _.. . . fl V k V_W_, . . . Date: (%2--f 11b I ------------------------------------------------------------------- ------------------------------------------------- _T_h_e__ _f6_11 -o- Wing Authorization Form is required to be completed by the property owner only when designating an agent of the propef ty owner to apply for a construction permit for the Owner -Builder). AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF Excluding the Notice to Property Owner, the execution of which I understand is my personal responsibility, -1,hereby authorize the following person(s) to act as my agent(s) to apply for, sign, and file the documents necessary to obtain an Owner -Builder Permit for my project. Scope of Construction Project (or Description of Work): Project Location or Address. Name of Authorized Agent: - Address of Authorized Agent: Tel No I declare under penalty of perjury that I am the property owner for the address listed above and I personally filled out the above information and certify its accuracy. Note: A copy of the property owner's driver's license, form notarization, or other verification acceptable to the city may be required to be presented when the permit is issued to verify the property owner's signature. Property Owner's Signature: Date: OwnerBuilderFom_2010.doc revised 04114110