11110101CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10055 N PORTAL AVE
CONTRACTOR: FRESH AIR MECHANICAL
PERMIT NO: 11110101
OWNER'S NAME: TRAINA ANGELO R TRUSTEE
5069 BENGAL DR
DATE ISSUED: 11/17/2011
OWNER'S PHONE: 4083691800
SAN JOSE, CA 95111
PHONE NO: (408) 438.7678
de LICENSED CONTRACTOR'S DECLARATION
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License Class Lic. N g 1 Z3 n 3
BUILDING PERMIT INFO: BLDG ELECT PLUMB
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Contractor C" Date
MECH RESIDENTIAL COMMERCIAL
I hereby affirm that I am licensed under the provisions of Chapter 9
JOB DESCRIPTION: FREESTANDING LIGHT POLE ON 10055 N PORTAL AVE.
(commencing with Section 7000) of Division 3 of the Business & Professions
ADJACENT TO THE EAST PROPERTY LINE OF 19875
Code and that my license is in full force and effect.
STEVENS CREEK BLVD REFERENCE KIDDIE ACADEMY PERMIT
I hereby affirm under penalty of perjury one of the following two declarations:
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.
I have and will maintain Worker's Compensation Insurance, as provided for by
Sq. Ft Floor Area:
Valuation: $0
Section 3700 of the Labor Code, for the performance of the work forwhich this
permit is issued.
APN Number: 31621088.00 Occupancy Type:
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
PERMIT EXPIRES IF WORK IS NOT STARTED
indemnify and keep h less the City of Cupertino against liabilities, judgments,
costs, and expenses ich may accrue against said City in consequence of the
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
granting of this pe ' . Additionally, the applicant understands and will comply
180 D S FROM L ALLED INSPECTION.
with all non -point rce gulati er the Cupertino Municipal Code, Section
9.18.
/ Date:
Signature Date-
Issued by:
OWNER -BUILDER DECLARATION
Ay
RE -ROOFS:
affirm that I am exempt from the Contractor's License Law for one of
All roofs shall be inspected prior to any roofing material being installed. If a roof is
the following two reasons:
installed without first obtaining an inspection, I agree to remove all new materials for
I, as owner of the property, or my employees with wages as their sole compensation,
inspection.
will do the work, and the structure is not intended or offered for sale (Sec.7044,
Business & Professions Code)
Signature of Applicant: Date:
1, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec.7044, Business & Professions Code).
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
I hereby affirm under penalty of perjury one of the following three
declarations:
I have and will maintain a Certificate of Consent to self -insure for Worker's
HAZARDOUS MATERIALS DISCLOSURE
Compensation, as provided for by Section 3700 of the Labor Code, for the
I have read the hazardous materials requirements under Chapter 6.95 of the
performance of the work for which this permit is issued.
California Health & Safety Code, Sections 25505, 25533, and 25534. 1 will maintain
I have and will maintain Worker's Compensation Insurance, as provided for by
compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health &
Section 3700 of the Labor Code, for the performance of the work for which this
Safety Code, Section 25532(a) should I store or handle hazardous material.
Additionally, should I use equipment or devices which emit hazardous air
permit is issued.
contaminants as defined by the Bay Area Air Quality Management District I will
I certify that in the performance of the work for which this permit is issued, l shall
maintain mpliance with the Cupertino Municipal Code, Chapter 9.12 and the
not employ any person in any manner so as to become subject to the Worker's
Health of e, Sections 25505, 2.5533, and 25534.
Compensation laws of California. If, after making this certificate of exemption, I
/:e�d
become subject to the Worker's Compensation provisions of the Labor Code, I must
Owne thor a enc
Date:
forthwith comply with such provisions or this permit shall be deemed revoked.
APPLICANT CERTIFICATION
CONSTRUCTION LENDING AGENCY
I certify that 1 have read this application and state that the above information is
I hereby affirm that there is a construction lending agency for the performance of work's
correct. 1 agree to comply with all city and county ordinances and state laws relating
for which this permit is issued (Sec. 3097, Civ C.)
to building construction, and hereby authorize representatives of this city to enter
Lender's Name
upon the above mentioned property for inspection purposes. (We) agree to save
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
Lender's Address
cos s and expenses which may accrue against said City in consequence of the
g=g of this permit. Additionally, the applicant understands and will comply
ARCHITECT'S DECLARATION
w non -point source regulations per the Cupertino Municipal Code, Section
9.
1 understand my plans shall be used as public records.
Signature Date
Licensed Professional
GENERAL PERMIT APPLICATION M E P
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 950143255 M /�
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FIPLUMBING 7MECHANICAL r&J ECTRICAL f 1A.rISM-tANcnrls
(408) 777-3228 •FAX (408) 777-3333 • buildin0(�cuoertinO.Or
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By my sigoaNre bel , I certify to ach of the following I am the pmperty Iwoer err authorized agent to act m the pmp owner's bchal£ I have read thus
application and the i ation I have provide is c ct a read the Description of Work and verify it is accurate. I agree to comply with 0 applicable local
ordinances and state laws relating to buil '
ons ction. authorize representatives of Cupertino to eater the above -identified property for inspection p4oses.
Signature of ApplicandAgmt�
Data: 1- t l - I r
SUPP
AL INFORMATION REQUIRED
OFFICE USE ONLY
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OUPERTINO
CONTRACTOR / SUBCONTRACTOR LIST
Building Department
City Of Cupertino
10300 Torre Avenue
Cupertino, CA 95014-3255
Telephone: 408-777-3228
Fax: 408-777-3333
JOBADDRESS: DO
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PERMIT# 1110 0
OWNER'S NAME: �
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PHONE # Lf A - 1139 - 6 8
GENERAL CONTRACTOR:
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BUSINESS LICENSE # 03Z
ADDRESS:,S'o6 &e^ dl d6-_
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*Our municipal code requires all businesses workin in the city to have a City of Cupertino business license.
NO BUILDING FINAL OR FINAL OCCUPA Y INSPECTION(S) WILL BE SCHEDULED UNTIL THE
GENERAL CONTRACTOR AND ALL SUB N A ORS HAVE OBTAINED A CITY OF CUPERTINO
BUSINESS LICENSE.
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following information:
Owner / Contractor Signature
((- 1 1 -it
Date
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SUBCONTRACTOR
BUSINESS NAME
BUSINESS LICENSE #
Cabinets & Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring / Carpeting
Linoleum / Wood
Glass / Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Painting / Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Roc
Tile
Owner / Contractor Signature
((- 1 1 -it
Date
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