B-2017-1768 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO;8-2017-1768
7539 TIPTOE LN CUPERTINO,CA 95014-5836(359 28 011) GREEN LINE
DEVELOPMENTINC
CAMPBELL,CA 95008
OWNER'S NAME: DATE ISSUED:06/19/2018
OWNER'S PHONE: PHONE NO:(
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class @ Lia#2=
Contractor GREEN LINE DEVELOPMENT INC Date 07/31/2018 X BLDG X ELECT X PLUMB
I herebyaffirm that I am licensed under the visions of Cha ter 9 X MECH X RESIDENTIAL_COMMERCIAL
a pro p (commencing
with Section 7000)of Division 3 ofthe Business&Professions Code and that my
license is In full force and effect. JOB DESCRIPTION:
IST FLOOR ENTRY,GARAGE,MASTER BEDROOM/BATHROOM;
I hereby affirm under penalty of perjury one ofthe following two declarations: WALK IN CLOSET;KITCHEN;DINING ROOM AND LIVING ROOM
t. I have and will maintain a certificate of consent to self-insure for Worker's ADDITION(1436 S.F.);REMODEL OTHER(2715 S.F.);(N)
Compensation,as provided for by Section 3700 ofthe Labor Code,for the FURNACE/SPLIT SYSTEM;TWO(N)TANKLESS WATER HEATERS;
performance of the work for which this permit is issued. RELOCATE GAS METER;UPGRADE ELECTRICAL SERVICE PANEL
z 1 have and will maintain Worker's Compensation bvsmance,as provided for by (200 AMPS);FIRE SPRINKLER BUILDING
Section 3700 ofthe Labor Code,for the performance ofthe work for which this
is correct.I agree to comply with all city and county ordinances APN Number: Occupancy Type:
and slate laws relating to building construction,and hereby authorize 359 28 Olt 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,casts,and expenses which PERMIT EXPIRES IF WORI{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=theclpal c section 9.16. 180 DAYS FROM LAST CALLED INSPECTION.
SignatureDate 06/19/2018 Issued by:Jasmine Archbold
Date:06/19/2018
OWNER-BUILDER
I hereby affirm that I am exempt from the Contractor's License Law]or one of the RE-ROOFS:
following two reasons: All roofs shall be inspected prior to any roofing material being installed.If a roof is
t. I,as owner ofthe property,or my employees with wages as their sole installed without first obtaining sit inspection,I agree to remove all new materials for
compensation,will do the work,and the structure is not intended or offered£m, inspection.
sale(Sce:7044,Business&Professions Code)
z 1,as owner ofthe property,am exclusively contracting with licensed Signature ofApplicauC
contractors to construct the project(See.7044,Business&Professions Code). Date:06/19/2018
I hereby affirm under penalty of perjury one of the following three declarations: ALL 1200E COVERINGS TO BE CLASS"A"OR BETTER
t. I have and will maintains Certificate of Consent to self-insure for Worker's
Compensation,as provided for by Section 3700 of the Labor Cade,For the
pas formance of the work for which this permit is issued. HAZARDOUS MATERIALS DISCLOSURE
t. I have and will maintain Worker's Compensation Insurance,as provided for by I have read the hazardous insist lots requirements ruder 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 25534.1 will
permit t is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the a. I certify that in the performance of the work for which this permit is issued,I Health.&Safety Cade,Section 25532(x)should I store or handle hazardous
material.Additionally,should I use equipment or devices which emit hazardmis
shall not employ any person in any manner so as to became subject to the r orumminants as defined by the Bay Area Air Quality Management District 1
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,l become subject to the Worker's Compensation provisions of the the health&Safety Code,Sections 25 5,2 3,
Labor Code,I must forthwith comply with such provisions or this permit shall
be deemed revoked. Owner or authorized agent:
APPLICANT CERTIFICA'ITON Date:06/19/2018
I certify that have read this application and state that the above information is CON TRATION
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 'TN
Code,
Signature Date 06/19/2018 Licensed
Professional
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2017-1768
7539 TIPTOE LN CUPERTINO,CA 95014-5836(359 28 011) GREEN LINE
DEVELOPMENT INC
CAMPBELL,CA 95008
OWNER'S NAME: DATE ISSUED:06/19/2018
OWNER'S PHONE: PHONE NO:(408)215-8007
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class GENERAL BUILDING CONTRACTOR Lie.#975092 BLDG X ELECT PLUMB
Contractor GREEN LINE DEVELOPMENT INC Date 07/31/2018
I hereby affirm that I am licensed under the provisions of Chapter 9(commencing MECH 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:
1ST FLOOR ENTRY,GARAGE,MASTER BEDROOM/BATHROOM
have and will maintain Worker's Compensation Insurance,as provided for by (200 AMPS);FIRE SPRINKLER BUILDING
"'"' Section 3700 of the Labor Code,for the performance of the work for which this .REV#1,,_SHEAR WALL ON B-LINE;KITCHEN RECONFIGURATION;
permit is issued. RELOCATION OF FURNACE-ATTIC;2 NEW SUB PANELS(100 AMP
APPLICANT CERTIFICATION EACH);-ISSUED 2/14/19
I certify that I have read this application and state that the above Sq.Ft Floor Area: Valuation:$400000:00
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 APN Number: Occupancy Type:
inspection purposes. (We)agree to save indemnify and keep harmless the 359 28 011 R-3(Custom)
City of Cupertino against liabilities,judgments,costs,and expenses which
may accrue against said City in consequence of the granting of this permit.
Additionally, a applicant urnderstands and will comply with all non-point
source regul. "ons pe he 6 u ertino Municipal Code,Section 9.18. PERMIT EXPIRES IF WORK IS NOT STARTED
�= g f WITHIN 180 DAYS OF PERMIT ISSUANCE OR
Signature
Date l ) 180 DAYS FROM LAST CALLED INSPECTION.
OWNER-BUILDER DECLARATION Issued by:jasmine Archbold
I hereby affirm that I am exempt from the Contractor's License Law for one of the Date:06/19/2018
following two reasons:
r. I,as owner of the property,or my employees with wages as their sole RE-ROOFS:
compensation,will do the work,and the structure is not intended or offered for All roofs shall be inspected prior to any roofing material being installed.If a roof is
sale(Sec.7044,Business&Professions Code) installed without first obtaining an inspection,I agree to remove all new materials for
2. I,as owner of the property,am exclusively contracting with licensed inspection.
contractors to construct the project(Sec.7044,Business&Professions Code).
I hereby affirm under penalty of perjuy one of the following three declarations: Signature of Applicant:
i. I have and will maintain a Certificate of Consent to self-insure for Worker's Date:
Compensation;as provided for by Section 3700 of the Labor Code,for the
performance of the work for which this permit is issued. ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
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 HAZARDOUS MATERIALS DISCLOSURE
permit is issued. I have read the hazardous materials requirements under Chapter 6.95 of the
3. I certify that in the performance of the work for which this permit is issued,I California Health&Safety Code,Sections 25505,25533,and 25534. I will
shall not employ any person in any manner so as to become subject to the maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
Worker's Compensation laws of California. If,after making this certificate of Health&Safety Code,Section 25532(a)should I store or handle hazardous
exemption,I become subject to the Worker's Compensation provisions of the material. Additionally,should I use equipment or devices which emit hazardous
Labor Code,I must forthwith comply with such provisions or this permit shall air contaminants as defined by t e Bay Area Air Quality Management District I
be deemed revoked. will maintain compliance with t r.Cupertino unicipal Code,Chapter 9.12 and
the Health&Safety C
correct.I agree to comply with all city and county ordinances and state laws Date:
relating to building construction,and hereby authorize representatives of this city IN IO ►It I 4 C
to enter upon the above mentioned property for inspection purposes. (We)agree I hereby affirm that there is a construction lending agency for the performance
to save indemnify and keep harmless the City of Cupertino against liabilities, of work's for which this permit is issued(Sec.3097,Civ C.)
judgments,costs,and expenses which may accrue against said City in Lender's Name
consequence of the granting of this permit. Additionally,the applicant understands
and will comply with all non-point source regulations per the Cupertino Municipal Lender's Address
Code,Section 9.18.
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Signature Date
Licensed