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B-2017-1236CITY OF CUPERTINO BUILDING PERMIT BVILDINGADDRESS: CONTRACTOR: PERMIT NO: B-2017-1236 11122 WILKINSON AVE CUPERTINO, CA 95014-4736 (356 17 073) DE ANZA INTERIOR INC SAN JOSE, CA 95129 OWNER'S NAME: CHEW GLEN JONE M AND KAREN D TRUSTEE OWNER'S PHONE: 408-506-6686 LICENSED CONTRACTOR'S DECLARATION License Class a Lic. #820996 Contractor DE ANZA INTERIOR INC Date 06/30/2019 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. I hereby affirm under penalty of perjury one of the following two declarations: 1. I have and will maintain a certificate of consent to self -insure for Worker's ISSUED• 07/27/2017 PHONE NO: (408) 861-0766 BUILDING PERMIT INFO - BLDG —ELECT —PLUMB MECH X RESIDENTIAL _ COMMERCIAL JOB DESCRIPTION 1 ST FLOOR BATHROOM REMODEL (51.5 SF) Compensation, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. Lz. 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: $5000.00 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 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. Additionally, the applicant understands and will comply with all non -point source regulations p the Cupertino] Municipal Code, Section 9.18. SignaturDate 07/27/2017 OWNER -BUIL DER DECLARATION 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 compensation, will do the work, and the structure is not intended or offered for sale (Sec.7044, Business & Professions Code) z. I, 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. I have and will maintain a Certificate of Consent to self -insure for Worker's APN Number -Occupancy Type: 356 17 073 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 permit is issued. s. 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 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. Additionally, the applicant understands and will comply with all non -point source regulations per the Cupertino Municipal Code, Section 9.18. Signature Date 07/27/2017 PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTION. Issued by Kim Dunbar Date: 07/27/2017 RF! -ROOFS: All roofs 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: 07/27/2017 ROOF COVERINGS'TO BE CLASS "A" OR BETTER 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. I will maintain compliance with the Cupelrtino Municipal Code, Chapter 9.12 and the Health & Safety Code, Section 25$32(a) should I store or handle hazardous material. Additionally, should I use equipment or devices which emit hazardous air contaminants as defined by the Day Area Air Quality Management District I will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Codel Sections 25505, 25533, and 25534. Owner or authorized agent:, Date: 07/27/2017 T TI N LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of work's for which this permit is issued (Sec. 3097, Civ C.) Lender's Name Lender's Address ARCHITECT'S DECLARATION I understand my plans shall be used as public records. Licensed Professional CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 CLtPERT I~I I (408) 777-3228 • FAX (408 777-3333 • buildinCipcupertino.org ,D T' _" 12 NEW CONSTRUCTION ❑ ADDITION �ALTERATIQ) Ti ❑ REVISION /DEFERRED ORIGINAL PERMIT # PROJECT ADDRESS i k I L VH G @ kiti h s-oAl M5 5 (.1A eti )'T o APN # 3574p a' OWNER NAME p"44 jI lL' PHONE E-MAIL d pw STREET ADDRESS 1 ! l 2_-a -a 11. Ke n ovave-1 CITY,• STATE, ZIP FAX CONTACT NAME � ' 1 q. PHONE ,ey .., { / STREET ADDRESS y Cy� (� CITY, STATE, ZIPf�j 7s�%7 �. _ FAX `` ` �7 (�N ❑: OWNER ❑ OWNER -BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER. ❑ TENANT CONTRACTOR NAME B LICENSE NUMBER ��� �(l LICENSE TYPE BTJS>L�kp COMPANY NAME �AA V6�✓7 L. �� /� l(1 EMAIL d � i l fYl�-4 rf � FAAXl�°X a j 7 � STREET ADDRESS I �'%3 �+� `7/i v' t W . CITY, STATE, ZIP ` 1p� :e e— ��17 PHONE � A® 6W �7�� ARCHITECT/ENGINEER.NAME "L LICENSE NUMBER ) BUS.LILC9 zf COMPANY NAME E-MAIL FAX STREET ADDRESS - CITY, STATE, ZIP PHONE DESCRIPTION OF WORK ; EXISTING USE. PROPOSED USE CONSTR. TYPE I I STORIES USE. TYPE OCC. SQ.FT. VALUATION ($) EXISTG NEW FLOOR DEMO TOTAL - - - AREA AREA AREA NET AREA BATHROOM KITCHEN OTHER - - - REMODEL AREA. REMODEL AREA REMODEL AREA t PORCH AREA DECK AREA TOTAL DECWPORCH AREA GARAGE AREA: FIDETACH _ - []ATTACH # DWELLING UNITS: IS A SECOND UNIT ❑ YES SECOND STORY F] YES BEING ADDED? ❑NO ADDITION? ❑NO - A `9 PRE -APPLICATION ❑ YES IF YES, PROVIDE COPY OF IS THE BLDG AN ❑ YESRE , $ T VAL TION: PLANNING APPL # ❑ NO PLANNING APPROVAL LETTER EICHLER HOME? ❑ NO By my signature below, I certify to each of the following: I am the property owner or authorized agent to 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 buildin onstruction. I authorize representatives of Cupertino to enter the above -identified property for inspection purposes. Signature of Applicant/A4 D 1-7— SUPPLEMEIWLIN ORMATION REQUI D� A New SFD or Multifamily dwellings: Apply for demolition permit for ` - OER THE COTIINTER ❑ BL ILDING P> A1S REVIEW existing building(s). Demolition permit is required prior to issuance of building s t46 permit for new building.CQ tixPrzEss g ❑ PLANNINGTE PLANRES)Y x _ Commercial Bldgs: Provide a completed Hazardous Materials :Disclosure sTANDAi2D ❑ pzIBLIwoRxs form if any Hazardous Materials are being used as part of this project. ❑r 7731'- F1iE llEI T, _ Copy of Planning Approval Letter or Meeting with Planning prior to �;VIAJ©R SAl�ITAiiYS>wCRTI[STRICT submittal of Building Permit application.' _. 41, �..,EINVIR011iVLEN,TAL'FtEAI TH BldgApp_201 Ldoe revised 06/21/11