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B-2016-2763CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: CONTRACTOR: PERMIT NO: B-2016-2763 10411 STERLING BLVD CUPERTINO, CA 95014-3831 (375 26 001) OWNER BUILDER OWNER'S NAME: MAHMOOD SHAHBAZ DATE ISSUED: 01/10/2017 OWNER'S PHONE: 408-205-5847 PHONE NO: LICENSED CONTRACTOR'S DECLARATION ATION BUILDING PERMIT INFO: License Class Lic. # Contractor OWNER BUILDER Date X BLDG X 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: TO CLEAR CODE ENFORCEMENT CASE: REBUILD EXISTING I hereby affirm under penalty of perjury one of the following two declarations: GARAGE (507 SQ FT); CONSTRUCT GARAGE ADDITION (115 SQ 1. I have and will maintain a certificate of consent to self-insure for Worker's FT); INSTALL 200 AMP SUB-PANEL AT (E) GARAGE EXTERIOR Compensation, as provided for by Section 3700 of the Labor Code, for the WALL. performance of the work for which this permit is issued. 2. I have and will maintain Worker's Compensation Insurance, as provided for by REVISION #2: REVISE SHEAR AT GARAGE-OPENING; SWITCH-: Section 3700 of the Labor Code, for the performance of the work for which this LOCATION OF SINK AND WATER CLOSET; RELOCATE SUB-PANEL; permit is issued. FIX BATHROOM WINDOW SIZE; ADD WINDOW. ISSUED 4.20.17 Sq. Ft Floor Area: Valuation: $10500.00 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 representatives of this city to enter upon the above mentioned property for 375 26 001 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 source regulations per the Cupertino Municipal Code, Section 9.18. WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTION. Signature Date 4.20.17 Issued by: SEAN HATCH OWNER BUILDER DECLAMATION Date: 01/10/2017 I hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: 1. I, as owner of the property, or my employees with wages as their sole RE-ROOFS: All roofs shall be inspected prior to any 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. r 2. I, as owner of the property, am exclusively contracting with licensed - y contractors to construct the project (Sec.7044, Business & Professions Code). Signature of Applicant: I hereby affirm under penalty of perjury one of the following three declarations: Date: 4.20.17 1. I have and will maintain a Certificate of Consent to self-insure for Worker's Compensation, as for by Section 3700 of the Labor Code, for the ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER provided 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 s. 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 hazardous 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 Additionally, should I use equipment or devices which emit hazardous Worker's Compensation laws of California. If, after making this certificate of material. as defined by the Bay Area Air Quality Management District I exemption, I become subject to the Worker's Compensation provisions of the air contaminants 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. APPLICANT CERTIFICATION Owner or authorised agent: i — I certify that I have read this application and state that the above information is Date: 4 20.17_ ! 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 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.) to save 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. ARCHITECTISDECLARATION I understand my plans shall be used as public records. Signature - Date 4.20.17 Licensed Professional CUPERTINO !� 'c� (6 CONSTRUCTION PERMIT APPLICATION. COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 � (408) 777-3228 • FAX (408) 777-3333 • building (u�cupertino.org I 1 I NI:w CnNCTRucTTnN n A1)IDTTTnN n ALTERATION / TI DEFERRED ORIGINAL PERMIT # PROJECT ADDRESS,10411 �� �� 6tv d %� � AI G7 D,� OwNERNAMEI PHONE �fi� �y _L l%� E-MAIL �4�'IGI�{i (f3Jf7 fl I mal `L STREET ADDRESS 1:?v CITY, STATE, ZIP � a j a `� � � F � I �L�l r 1 `✓'MAIL FAX CONTACT NAME �aweas �F 1As�^ W 6•V PHONE ' E- STREET ADDRESS CITY, STATE, ZIP FAX ❑ OWNER OOWNER-BUBAER ❑ OWNER AGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT t� CONTRACTORNAM& Way,-LICENSE a LICENSE �4 NUMBER LICENSE TYPE BUS. LIC# COMPANY NAME E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE ARCHITECT/BNGE LEER NAME LICENSE NUMBER BUS. LIC # COMPANY NAME E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE g� DESCRIPTION OF ORK 111!lla���YYY "l } � W `V � eat 9+�l10✓li W 4 �° EXISTING USE PROPOSED USE CONSTR TYPE # STORIES USE TYPE OCC. SQ.FT. VALUATION ($) EXISTG NEW FLOOR DEMO AREA TOTAL NETAREA - AREA AREA BATHROOM REMODEL AREA KITCHEN REMODEL AREA OTHER REMODEL AREA PORCH AREA DECK AREA TOTAL DECK/PORCH AREA GARAGE AREA: DETACH ❑ ATTACH # DWELLING UNITS: IS A SECOND UNIT ❑ YES SECOND STORY ❑ YES BEING ADDED? []NO ADDITION? ❑ NO PRE -APPLICATION ❑ YES IF YES, PROVIDE COPY OF PLANNING APPL # ❑ NO PLANNING APPROVAL LETTER IS THE BLDG AN ❑ YES EICHLER HOME' ❑ NO REC IVED BY: e TOTAL VALUATION: By my signature below, I certify to each of the following: I am the property owner or authorized agent to act on e 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 constructio - I authorize representatives of Cupertino to enter the above -identified property for inspection purposes. Signature of Applicantlt !gent: Date: 04 / 2-0 Zca f SUPPLEMENTAL INFORMATI 94EQUIRED PLAN CBECK _TYPE ROUTING SLIP p OVER-THE-COUNTER ❑ BUILDING PLAN REVIEW New SFD or Multifamily dwellings: Apply for demolition permit for _ existing building(s). Demolition permit is required prior to issuance of building permit for new building. ❑ EXPRESS ❑ PLANNING PLAN REVIEW Commercial Bldgs: Provide a completed Hazardous Materials Disclosure ❑ STANDARD ❑ PUBLIC WORKS _ form if any Hazardous Materials are being used as part of this project. ❑ LARGE ❑ FUZE DEPT _ Copy of Planning Approval Letter or Meeting with Planning prior to ❑ MAdoR ❑ .-SANITARY SEWER DISTRICT submittal of Building Permit application. ❑ ENVIRONNfENTAL HEALTH BldgApp_2011.doc revised 06121111 _ CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: ___... jCONTRACTOR PERMIT NO. ii -2016-3763 10411 STERLING BLVD CUPERTINO, CA 95014-3831 (375 26 001) t OWNER BUILDER 1OWNEWS NA.MEt MAHM00I) SIIAliBAZ 1 IDAxE ISSUED, 01/1012017 -1 OWNER'S PIIOlvE: 408-205-584.7; PrrONE fret: u--) I IC'ENSED C:ONTRACTOR'S DECLARATLON License Class Lie. # Contractor OWNER BUILDER Date I hereby affirm that I amt licensed under the provisions of Chapter 9 (commencing with Section 7000) of Division 3 of tate Business & Professions Code and that my license is in full force and effect. 11 hereby affirm under penalty of perjury one of the following two declarations: r. t have and will maintain a curtiftcatc of consent to self -insure for Worker's Compensation, as provided for by Section 370€1 ofthe Labor Code, for the performance of the work for which this permit is issued. z. 1 have and will maintain. worker's Compensation insurance, as provided for by Section 3700 ofthe Labor Code, for the perforrnance of tic work for which this j permit is issued. j APPLICANT €'ERTTFIC kTTON ! 1 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. (Vile) agree to save indemnify and keep harmless the j City of Cupertino against liabilities, judgments, costs, and expenses which lmay 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 3,18, Signature Date 3.30.17 OWVER-BTIILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: L 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 (Sce.7044, Business & T'rofessions Code) z. 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: 1. T have and will maintain a Certificate ofConscnt to stir -insure for Worker's Compensation, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this pert -nit is issued. z. 1 have:amd 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. I certify that in the performance of the work for which this permit is issued, I 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 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 l 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 bultding 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 consequents 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. Signature LL__ Date 3.30.17 BUILDING PERMIT INFO: X BLDG X ELECT —PLUMB _ IMECH X RESIDENT'IAL,,,,,, COMMERCIAL JOB DESCRIPTION: TO CLEAR CODE ENFORCEMENT CASE: REBUILD EXISTING GARAGE (507 SQ FT); CONSTRUCT GARAGEAIDD17FION (115 SQ FT); INSTALL 200 AMP SUB -PANEL AT (E) GARAGE EXTERIOR MALL. REVISION #1: ADD ADOOR AND WINDOIV TO STORAGE AREA AT BACK OF DETACHED GARAGE. ISSUED 3,30.17 Sq. Ft Floor Area: l Valuation: $10500.09, I APN Number: Occupancy Type: 1375 2f 001 PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTION. Issued by: SEAN HX17CH Date: 01110/2017 RI~-ROC}FS- rill roofs shall be inspected prior to any rooting material being installed. If a roof is installed widtour first obtaining an inspection, I agree to remove all new materials for inspection. Signature of Applicant: Data: 3.30.17 ALLROOF COVERINGS TO BE CLASS "A" OR BETTER HAZARDOUS MATERIALS DISCLOSURE I have read tate hazardous materials requirements under Chapter 6.95 of, the California Health &a Safety Code, Sections 25505, 25533, and 25534. I ;will maintain compliance with the Cupertino Municipal Code, Chapter 9,12 and the Health & Safety Code, Section 25532(a) should I store or handle hazardous material. ,additionally, should I use equipment or devices which emit hazardous stir contaminants as defined by the Day Area Air Quality Management District l will maintain compliance with the Cupertino Municipaal Code, Chapter 9.12 and theHealth 8z Safety Coda, Senates 25505, 25f 33, and 21534. Owner or authorized agent: Date: 3.30.17 CONSTRIFCTION I. ,: DINGAGEi CY 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 RC I1fECI'S DECLARATION understand my plans shall .be used. as public records. Licensed Professional CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT - BUILDING -DIVISION 10300 TORRE AVENUE - CUPERTINO, CA 95014-3255 (408) 777-3228 - FAX (408) 777-3333 - building@gMpertino.org DNEW CONSTRUCTION 0 ADDITION Q ALTERATION !TJ REVISION i DEFERRED ORIGINAL PERMIT # PROJECT ADDRESS 4 11 sie b I vJ C") a7u� CA �J'tJ 41 APN* OWNERNAME PHONNE --7MAIL 6a?4OR Q4 STREET ADDRESS end CITY, STATE, ZIP CONTACT NAME JZ' #Jahrnoo NIONTE 4o a --2 E4HAIL M yrk-,Oj STREET ADDRESS CITY, STATE, ZIP 5 PAX t'u 8 OWNER 11 OWNER -BUILDER El OWNERAGENT rl CONIRACTOR 000NTRACTORAGEN'T 0 ARCHITECT DENIGINEER 1-1 DEVELOPER OTEN,41W CONTRACTOR NAME LICENSE imi,4BER LICENSE TYPE BU& LIC It COMPANY NAME _7 E-MAIL FAX STREETADDRMS CITY, STATr,. 7.1 P PHONE ARC14,11'ECTft-NC,INEL-'IINA�,ir. LICENSE NUMBER GUTS. LIC 4 COMPANYNANIE IL FAX S VREETADDRESS CITY, STATE, ZIP PHONE DESCRIPTION OF INORK aa CL Wvnjow to VQ EXISTING USE PROPOSED USE CONSTR. TYPE. r STORIES USE TYPE OCC. SQXT. VALUATION EXISTG "�'Bv MOM DE4iO iy)TAI. AREA AREA, AREA NEI AREA BATHROOM KITCHEN OTHER 1*-*,IODELAPEA M, JODU A"A REMODELAREA PORCHAREA DECK AREA AREA GARAGEAREA: DDETACH J­���ORCH [JATTACK I 4 DWELLING UNITS: IS A SECOND IMF 0 YES SECOND STORY ®YES ]BEINGADDED? ©NO ADDITION? []NO VALUATION: PRE,APPILICATION ®YES IF YES, PROVIDE COPY Of ISTHEMMAN ©YES- , RECELW-D BY: +TOTAL PI_ANNFN'eAPPL&' ©NO PLANNNla APPROVAL LETTER EICHLER UONIE-1 DNO 'a By iry signature below, I certifv to each of the following: I ain the property owner or authorized agent to act on the property owner's behalf. I have read this application and the information I bane provided is correct. 1 e 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 constructio thorize representatives of Cupertino to enter the above -identified property forinsptN'fion purposes. Signature of Applicant/Agent- _ 11 1 Date: I -i'ci 10— SUPPLEMENTAL INFORMATION IRED ROUTING SLIP qLOVER 4 E -COUNTER UrLDINGPLANREVIENV New SFD or Multifamily dwellings: Apply for demolition permit for existing building.(S). Demolition permit is required prior to issuance of building perinit for new building. EXPRESS, -qQLANNJN(; PLAINREVIPW _. Ctlmnlercial Bldgs: Provide a completed Hazardous Materials Disclosure ❑ STMN'DARD Punic NN.-ORK's forin if. any Hazardous Materials are being used. as pail of this project. El LARGE ❑ rME DEPT Copy of Planning Approval Letter or Meeting with Planning prior to ❑ AWOR iu--binittal of Building Permit application, ENVIRONIMENTLL�HEALT. BldgApp_,2017,doci-ei,isedO6l'21111 im CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: CONTRACTOR: P POMNO: B-2016-2763 10411 STERLING BLVD CUPERTINO, CA 95014-3831 (375 26 001) OWNER -BUILDER OWNER'S NAME: MAHMOOD SHAHBAZ DTE ISSUED: 01/10/2017 OWNER'S PHONE: 408-205-58-47 P11 ONE NO: LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT O: License Class Lic. # Contractor OWNER -BUILDER Date X_ BLDG X ELECT — P UMB I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing — MECH X RESIDENT AL — COMMERCIAL with Section 7000) 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 of the following two declarations: TO CLEAR CODE ENFORCEMENT CASE: REBUILD EXISTING GARAGE (507 SQ FT); CONSTRUCT GARAGE ADDITION (115 SQ 1. I have and will maintain a certificate of consent to self -insure for Worker's FT); INSTALL 200 AMP UB -PANEL AT (E) GARAGE EXTERIOR Compensation, as provided for by Section 3700 of the Labor Code, for the WALL. 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 permit is issued. Sq. Ft Floor Area: Valuation: $10000.00 APPLICANT CERTIFI &TION 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: Oc upancy Type: and state laws relating to building construction, and hereby authorize 375 26 001 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 EXPIR ZS IF WORK IS NOT STARTED may accrue against said City in consequence of the granting of this permit. Additionally, the applicant understands and will comply with all non -point WITHIN 180 D SOF PERMIT ISSUANCE OR source regulations per the Cupertino Municipal Code, Section 9.18. 180 DAYS FRO LAST CALLED INSPECTION. Signature Date 01/10/2017 Issued by: Kim Dunbar Date: 01/10/2017 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 p dor to any roofing 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) QI, as owner of the property, am exclusively contracting with licensed Signature of Applicant: contractors to construct the project (Sec.7044, Business & Professions Code). Date: 01/10/2017 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. HAZARD MATERIALS DISCLOSURE 2. 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 of the Labor Code, for the performance of the work for which this California Health & Safe ty Code, Sections 25505, 25533, and 25534. I will permit is issued. maintain compliance with t e 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 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 as 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 Cupertino Municipal Code, Chapter 9.12 and exemption, I become subject to the Worker's Compensation provisions of the the Health & Safely Code, Sections 255 5533, and 25534. Labor Code, I must forthwith comply with such provisions or this permit shall be deemed revoked. <- :.Owner or authorized agent: APPLICANT CERTIFICATION Date: 01/10/2017 1 certify that I have read this application and state that the above information is CONSTtUCTION LENDING AGENCY correct. I agree to comply with all city and county ordinances and state laws I hereby affirm that there isa 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 MunicipalARLEUTECT'SDECLARATION Code, Section 9.18. 1 understand my plans scall be used as public records. Signature Date 01/10/2017 Licensed Professional M CUPERTINO- ❑ NMV CONSTRUCTION CONSTRUCTION PERMIT APPLICATION name COMMUNITY DEVELOPMENT DEPARTMENT - BUILDING DIVISION 10300 TORRE AVENUE CUPERTINO, CA 95014-3256 (408) 777-3228 - FAX (408) 777-3333 • buildinc rr?�up�rtitlo.orcl L.....t ADDITION . ❑ ALTERATION/T1 ❑ REVISIONIDEFERRED1 ORIGINAL PERMIT # PROIECT ADDRESS loo `+ c i �� �, - , ` j] V CJ4 -�I`� APNTT PJ . SIC - I ��- mom_ }'ilbfl PHox£�o8 �`;. aVJNERNAM£ •M.a'z' `g STREET ADDRESS r t t ` t CITY, STATE, 7.IP p.9 p FAX CONTACTNAME 1�[C1yI�O l PHONE��{�U' -MAIL STREETADDRESS i }, CITY, STATE, ZIP D41OWNER 13 o-AwRBUn.DBR ❑ OWNER AGENT ❑ CONTRACTOR ❑ CONTRACTORAGENT ❑ ARcHITEcr ❑ ENc3INEER ❑ DEVELOPER ❑ TENANT CONTRACTORNAME f2 LIC£135EhUMBER LICENSETY E BUS. LIC COMPANY NAME E-MAIL FAX STREETADDRESS CITY, STATE, ZIP PHONE ARcHITEMENGMI ER NAME LICENSE NUMBER BUS. LTC I COMPANYNAME EMAIL FAX STREET ADDP.EM CITY, STATE, ZIP PHONE DESCRIPTION OF WORK EXISTING USE PROPOSED USECONSTR. T"Y'PE � STOR(Es USE TYPE OCC. SQ.ET. VALUATION (S) EXTSTG NEW FLOOR s DEMO TOTAL AREA AREA AREA NET AREA BATHROOM KITCHEN OT11FR REMODELAREA REMODELAREA RFAODELAREA PORCIi AREADECK AREA TOTAL DECKJpORCH AREA GARAGE AREA: DETACH ❑ ATTACH 0 DWELL1140 UNITS: 1S A SECOND UNIT []YES SECOND STORY ❑ YES BEING ADDED? []NO ADDITION? []NO PRE -APPLICATION' ❑YEs IF YES,PROVIDE COPY OF ISTHEBLDGAN ❑YES n;RECl✓ . ED, y "- .r r =w�-� ::: �_ TOTALVALUATION: PLAI.'].'Ii+IO APPLn ❑NO PLANNING APPROVAL LEITER EICHLE1t.T30Atk:: ❑ NO �y ivy signature below, I certify to each of the following: I ant the property owner or authorized agent to et on e p operty owner's behalf. I have read this application and the information I have provided is ca have read the Description of Work and eerify it is accurate. I agree to comply with all applicable local ordinances and state laws relating to building consn n, I authorize representatives of Cupertino to enter the above identified property for inspection purposes. Signature of Applicant/Agent: — Date: 06-- 2,o" 'U16 SUPPLEMENTAL IIIPOP UQIRED w rni i it=13[x=COT�is iE 1, T HE Nnv SFD or Multifamily dwellings: Apply for demolition permit for -- v existing building(s). Demolition permit is required prior to issuance of buildtnn -C.__ .; ? - : •:-• ��:_ r_> : tri »'<� : _.-�`; = _T a;��1_•: w:,_:;c>`: _ %-=n, permit for new ouildin ifl..?-ENate_ .95 9s 9iAiQ?tLAGPL;e1N Commercial Bldgs: Provide a completed Hazardous Materials Disclosure _- fot nI if any Hazardous Materials are being used as part of this project.` = Copy of Planning Approval Letter o1 4eetln. with Planning poor to >_0__: ---»h-•L-A E:-=i�--R D= --i: _Sw,T RC;. �- su_bmits I of Buildina Permit application. _ S_`C+=R'- ..: ^->-.---�._ -_.r:�:_- - �-:=-__sw.•;_- ;T . : _-_ E .IROn'2iSENTAT=.T� Bldg-App_2017.doc revised 06121/11 CUPE.RTINO OWNER -BUILDER DISCLOSURE FORM COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DI' 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 •FAX (408) 777-3333 • buildinq(a)cupertino.orA Dear Property Owner(s): An application for a building_ permit has been submitted in your name listing yourself improvements specified at: the builder of the property SITE ADDRESS Ib4r1 Sxti- Ui�(_, &v j) APN i P#_201 (� OWNER NAME sQ14&%�, _KlAtWOOD OWNER ADDRESS IQ4111 YtRuwj U\; i3 DESCRIPTION OF WORK: C �I�L r= RehADDEL We are providing you with an Owner -Builder Acknowledgment and Information Verific tion Form to make you aware of your responsibilities and possible risk you may incur by having this permit issued in yc ur name as the Owner -Builder. We will not issue a building permit until you have read, initialed your understandinc of each provision, signed, and returned this form to us at our official address indicated. An agent of the owner annot execute this notice unless you, the property owner, obtain the prior approval of the permitting authority. OWNER'S ACKNOWLEDGMENT AND VERIFICATION OF INFORMATION (DIRECTIONS: Please read and initial each statement below to signify you understand or verify this information.) 1. I understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner - Builder" building permit that erroneously implies that the property owner is providing his or her own labor and material personally. I, 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 andam aware of the limits of my insurance coverage for injuries to workers on my property. Z'�'-72. I understand building permits are not required to be signed by property oners unless they are responsible for the construction and are not hiring a licensed Contractor to assume this rest i ility. 403. 1 understand as an "Owner -Builder" I am the responsible party of record oil the permit. I understand that I may protect myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her name instead of my own. 4. 1 understand Contractors are required by law to be licensed and bonded in California and to list their license numbers on permits and contracts. 5. I understand if I employ or otherwise engage any persons, other than Cal otal value of my construction is at least five hundred dollars ($500), including [at considered an "employee' understate and federal law. I understand if I am considered an "employer' under state and federal lav federal government, withhold payroll taxes, provide workers' compensation disat unemployment compensation for each "employee." I also understand my failure i me to serious financial risk. 7. 1 understand under California Contractors' State License Law, an Owner• residential structures cannot legally build them with the intent to offer them for sc licensed subcontractors and the number of structures does not exceed four withi is performed under contract with a licensed general building Contractor. �8. 1 understand as an Owner -Builder if I sell the property for which this pern any financial or personal injuries sustained by any subsequent owner(s) that res defects in the workmanship or materials. -nia licensed Contractors, and the and materials, I may be , I must register with the state and lity insurance, and contribute to abide by these laws may subject uilder who builds single-family :, unless all work is performed by any calendar year, or all of the work is issued, I may be held liable for from any latent construction 2010.doc revised 04/14/10 4ev9. 1 understand I may obtain more information regarding my obligations as a "employer" from the Internal enue Service, the United States Small Business Administration, the California Department of Benefit Payments, and the California Division of Industrial Accidents. 1 also understand I may contac the California Contractors' State License Board (CSLB) at 1-800-321-CSLB (2752) or www.esib.ca.gov for more in ormation about licensed contractors. 7 10. 1 am aware of and consent to an Owner -Builder building permit applied for in my name, and understand that I am the party legally and financially responsible for proposed construction activity at the site address listed above. 11. 1 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 asemployers. 12. 1 agree to notify the issuer of this form immediately of any additions, del( information I have provided on this form. Licensed contractors are regulated by k you contract with someone who does not have a license, the Contractors' State L assist you with any financial loss you may sustain as a result of a complaint. You Contractors may be in civil court. It is also important for you to understand that if employee of that individual or firm is injured while working on your property, you you obtain a permit as Owner -Builder and wish to hire Contractors, you will be re those Contractors are properly licensed and the status of their workers' compens CONSTRUCTION LENDING AGENCY (DIRECTIONS: Please complete the following construction lending agency I hereby affirm that there is a construction lending agency for the performance of (Sec 3097 Civ.) Lender Name: Lender Address: ions, or changes to any of the vs designed to protect the public. If ,ense Board may be unable to only remedy against unlicensed n unlicensed Contractor or iay be held liable for damages. If ponsible for verifying whether or not tion insurance coverage. work for which this permit is issued 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 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: C) i — /®-- 2�LA� W ----------------------------------------------------------------------------------------------- ----------------------------------------- (NOTE: The following -Authorization -Form -is required to be completed by the propert owner only when designating an agent of the property owner to apply for a construction permit for the Owner -Builder). Excluding the Notice to Property Owner, the execution of which I understand is my p authorize the following person(s) to act as my agent(s) to apply for, sign, and file the 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 I declare under penalty of perjury that I am the property owner for the address listed above information and certify its accuracy. Note: A copy of the property owner's driv( verification acceptable to the city may be required to be presented when the permit h signature. 62 Property Owner's Signature: Date: al responsibility, I hereby vents necessary to obtain an bove and I personally filled out the -'s license, form notarization, or other issued to verify the property owner's 0/-/0 2010.doc revised 04114110 JF DESIGN AND ENGINEERING 408.512.8400 DATE: 11.29.2016 TO: City of Cupertino FROM: Jose Fernandez P.E. SUBJECT: 10411 Sterling Blvd, F I =5 qjR This letter is to confirmed that I have reviewed the slab thickness and the reinforcement for garage while it was formed prior to cement placement and determine that it is acceptable. Placed slab was place at 4" thickness and #4 bars where place at 16" o.c. Each way. Please accept this letter as inspection letter. If you have any questions, please call me. Sincerely, VES /0, �Qk S FFR F2 � o C 76349 N ,t EXP 12/31/16 ,t Jose C. Fernandez CMS �P 408.512.8400 3001 WINCHESTER BLVD • SUITE 8 • CAMPBELL, CA • 95008 PHONE: 408.512.8400 • FAX 408.800.4038