B-2018-0226�.
NO FEE FOR RECORDING PURSUANT TO
GOVERNMENT CODE SECTION 27383
When Recorded Mail To:
City of Cupertino
Community Development Department
10300 Torre Avenue
Cupertino, CA 95014
24184729
Regina A1comendras
Santa Clara County - Clerk -Recorder
05/22/2019 08:50 AM
Titles: 1 Pages: 3
Fees: $0.00
Taxes: 10.00
0
Total:
1111 Fan'r 91"KAIN111" IV
NOTICE OF SIDEYARD RESTRICTIONS
The undersigned, being the owner(s) of the property shown in the Santa Clara County Assessor's Roll and
identified as A.P.N. 366-18-031 and addressed as 1389 Poppy Way hereby agree(s) that the south elevation (left
side) is the conforming side with a setback of 5'-0" and the north elevation (right side) is the non -conforming side
with a setback of 5'-0". Any future additions along north elevation (right side) must be setback at least 10'-0"
(and/or subject to the discretionary approval of the City of Cupertino) in order to provide a combined side yard
setback of 15'-0". This declaration is binding on successors and assigns of the owner(s).
PROPERTY OWNER(S):
„v
Owner's Signature
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Print Owner's Name
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Date
CITY AUTHORIZATION:
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Erika Poveda, Assistant Planner
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Co -Owner's Signatt e
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Print Co -Owner's Name
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Date
CALIFORNIA ALL-PURPOSE CERTIFICATE OF ACKNOWLEDGMENT
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 Santa Clara
On before me, Kirsten Squarcia No
tary Public,
(Here insert name and title of the officer)
f
personally appeared E e-r Z (16V L/1
who proved to me on the basis of satisfactory evidence to be the person whose name(4 is/are subscribed to
the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized
, 0"_�
and that by his/her/their signature(4 on the instrument the perso , or the entity upon behalf of
capacity(i
which the person° acted, executed the instrument.
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 Seale KIRSTEN SQUARCIA
�.. Notary Public - California
Santa Clara County n
Commission # 2257322
My Comm. Expires Oct 4, 2022
Signa e of Notary Public
(Notary Seal)
ADDITIONAL OPTIONAL INFORMATION
DESCRIPTION OF THE ATTACHED DOCUMENT
(Title or description of attached document)
(Title or description of attached document continued)
Number of Pages Document Date
(Additional information)
CAPACITY CLAIMED BY THE SIGNER
❑ Individual (s)
❑ Corporate Officer
(Title)
❑ Partner(s)
❑ Attorney -in -Fact
❑ Trustee(s)
❑ Other
INSTRUCTIONS FOR COMPLETING THIS FORM
Any acknowledgment completed in California must contain verbiage exactly as
appears above in the notary section or a separate acknowledgment form must be
properly completed and attached to that document. The only exception is if a
document is to be recorded outside of California. In such instances, any alternative
acknowledgment verbiage as may be printed on such a document so long as the
verbiage does not require the notary to do something that is illegal for a notary in
California (i.e. certifying the authorized capacity of the signer). Please check the
document carefully for proper notarial wording and attach this form if required.
• State and County information must be the State and County where the document
signer(s) personally appeared before the notary public for acknowledgment.
• Date of notarization must be the date that the signer(s) personally appeared which
must also be the same date the acknowledgment is completed.
• The notary public must print his or her name as it appears within his or her
commission followed by a comma and then your title (notary public).
• Print the name(s) of document signer(s) who personally appear at the time of
notarization.
• Indicate the correct singular or plural forms by crossing off incorrect forms (i.e.
he/she/ is /tee ) or circling the correct forms. Failure to correctly indicate this
information may lead to rejection of document recording.
• The notary seal impression must be clear and photographically reproducible.
Impression must not cover text or lines. If seal impression smudges, re -seal if a
sufficient area permits, otherwise complete a different acknowledgment form.
• Signature of the notary public must match the signature on file with the office of
the county clerk.
Additional information is not required but could help to ensure this
acknowledgment is not misused or attached to a different document.
❖ Indicate title or type of attached document, number of pages and date.
❖ Indicate the capacity claimed by the signer. If the claimed capacity is a
corporate officer, indicate the title (i.e. CEO, CFO, Secretary).
• Securely attach this document to the signed document
C 2004-2015 ProLink Signing Service, Inc. — All Rights Reserved www.TheProLink.com — Nationwide Notary Service
CALIFORNIA 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:5 411 C/� 4/y
On 010/ before me,
141 1 Frank Matthew Dias, Notary Public
Date Here Insert NP-me aopf Title of the Office
personally appeared �c`���'r hl-Ff 6f A'cj ( 7 +Z-1 60
/j 41 r t 0 /f��� Name(s)
s) of Signer(s)
who proved to me on the basis of satisfactory evidence to be the person�sj whose name(�
4 0�are subscribed
77, .
to the within instrument and acknowledgedtome that /sVe/th-ey executed the same in6 KS/�WE!r/tbeir_
authorized capacityfi&W, and that by signature he instrument the person
,.,�n t or the entity
upon behalf of which the personisj acte executed the instrument.
lmAEL . M, _,WM& AOL .0L. Aft
FRANK MATTHEW DIAS
Notary Public -- California Z
Santa Clara County >
Commission # 2187614
My Comm. Expires Mar 23, 22021
Place Notary Seal andlor 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.
Signaturei"Poo
Signature oKNotoiy Public
Wr I IM111M.
Completing this information can deter alteration of the document or
fraudulent reattachment of this form to an unintended document
VDescription of Attached Document
Title or Type of DocumerX. Ce
Document Date, _____�l �Gi
Signer(s) Other Than Named Above:
Capacity(les) Claimed by Signer(s)
Signer's Name:
0 Corporate Officer — Title(s):
11 Partner — 11 Limited n General
C
,�'�sflkt�P
Number of Pages. -
Signer's Name:
• Corporate Officer —
• Partner — 11 Limited
• Individual 0 Attorney in Fact 0 Individual
• Trustee o Guardian of Conservator 0 Trustee
Titles):
0 General
11 Attorney in Fact
0 Guardian of Conservator
[I other: 0 Other:
Signer is Representing: Signer is Representing:
02017 National Notary Association
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS; CONTRACTOR; PERMIT NO:B-2018-0226
1389 POPPY WAY CUPERTINO,CA 95014-5304(366 18 03 1) ALIS CONSTRUCTION
&REMODELING INC
SAN JOSE,CA 95129
OWNER'S NAME: DATE ISSUED;04/06/2018
OWNER'S PHONE: PHONE No:(
LICENSED CONTRAC'TOR'S DECLARATION BUILDING PERMIT INFO:
License Class B Lip.#909433
Contractor ALPS CONSTRUCTION&REMODELING INC Date 01/31/2020 X BLDG X ELECT_PLUMB
MECH X RESIDENTIAL COMMERCIAL
1 hereby affirm that 1 am licensed ander 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:
ADDITION OF LIVING ROOM AND GUEST SUITE(676 S.F.);(N)
I hereby affirm under penalty of perjury one of the following two declarations: FRONT PORCH(24 S.F.);KITCHEN REMODEL(248 S.F.);
t. I have and will maintain a certificate of consent to self-insure for Worker's BATHROOM REMODEL(9 L25 S.F.);REMODEL OTHER(930,75 S.F);
Compensation,as provided for by Section 3700 cribs Labor Code,for the UPGRADE(E)ELECTRICAL PANEL TO 200 AMP
performance of the work for which this permit is issued.
z. I have and will maintain Worker's Compensation Insurance,as provided for by
issued. Sq.Ft Floor Area:676 Valuation:$172000.00
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 AIN Number: Occupancy Type:
and stale laws relating to building construction,and hereby authorize 366 18 031 R-3(Cuslom)
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 of the granting of this permit. WITHIN 180 DAYS OF PERMIT ISSUANCE OR
Additionally,the applicant understands and will comply with all non-point
source regulations lino Municipal Code,Section 9.18, 180 DAYS FROM LAST CALLED INSPECTION.
Signature Date 04-06-2018 Issued by:Kim Dunbar
Date:04/06/2018
OWNER-BUILDER DECLARATION
1 hereby aRirat that I at exempt from the Canmaefor's License Law for one of the RE-ROOFS
following two reasons: All roofs shall be inspected prior 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 ail new materials for
compensation,will do the work,and the structure is not intended or offered for inspection.
sale(Sm.7044,Business&Professions Code)
z. I,as owner of the property,am exclusively contracting with licensed Signature of Applicant:
contractors to construct the project(Scc.7044,Business&Professions Code), Date:04-06-2018
1 hereby affirm under penalty ot'porjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
t. 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,far the
performance of the work for which this permit is issued. HAZARDOUS MATERIALS DISCLOSURE
z. I have and will maintain Worker's Compensation Insurance,as provided for by I have read the hazardous nmateinls requirements trader 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. maintain compliance with the Cupertino Municipal Cade,Chapter 9.12 and the
s. I certify that in the performance of the work for which this permit is issued,I n 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 1 use equipment or devices which emit hazardous
Worker's Com sensation lows of California.I(,after e—in This certificate of contaminants as defined by the Bay Area Air Quality Management District 1
1 6 air
vfllmaintain compliance with the Cupertino Municipal Code,Chapter 9.12 and
exemption,I became subject to the Worker's Compensation provisions of the the HeNth&Safety Code,Sections 25505,1 533,and 25534.
Labor Cade,I must forthwith comply with such provisions or this permit shall
be deemed revoked. Owner or authorized agent:
APPLICANT CIr,RT'lF1CA'1'[ON Date:04-06-2018
I certify that I have read this application and State that the above information is CONSTRUCTION
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.
Licensed
Signature Date 04-06-2018 professional
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO: B-2018-0226
1389 POPPY WAY CUPERTINO, CA 95014-5304 (366 18 03 1) ALI'S CONSTRUCTION
& REMODELING INC
SAN JOSE, CA 95129
OWNER'S NAME: DATE ISSUED: 04/06/2018
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 01/31/2020 X BLDG X ELECT _ PLUMB
I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing X 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:
ADDITION OF LIVING ROOM AND GUEST SUITE (676 S.F.); (N)
I hereby affirm under penalty of perjury one of the following two declarations: FRONT PORCH (24 S.F.); KITCHEN REMODEL (248 S.F.);
Section 3700 of the Labor Code, for the performance of the work for which this
permit is issued. Sq. Ft Floor Area: 676 Valuation:. $172000,00
APPLICANT CERTIFICATION
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 Number: Occupancy Type:
and state laws relating to building construction, and hereby authorize 36666 18 031 R-3 (Custom)
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 of the granting of this permit. WITHIN 180 DAYS OF PERMIT ISSUANCE OR
Additionally, the applicant understands and will comply with all non-point
source regulations per the Cupertino Municipal Code, Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
SignatureJ Date 1/10/19 Issued by: Kim Dunbar
Date: 04/06/2018
OWNER-BUILDE
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 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)
2. I, as owner of the property, am exclusively contracting with licensed Signature of Applicant:
contractors to construct the project (Sec.7044, Business & Professions Code). Date: 1/10/19
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. HAZARDOUS 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 & Safety Code, Sections 25505, 25533, and 25534. I will
permit is issued. maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
3. I certifythat in the erformance of the work for which this permit is issued I Health & Safety Code, Section 25532(a) should I store or handle hazardous
p p
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 & Safety Code, Sections 25505, 25533, 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: 1/10/19
I certify that I have read this application and state that the above information is CONSTRUCTION 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. I understand my plans shall be used as public records.
Licensed
Signature Date 1/10/19 Professional