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12070200 CITY OF CUPERTINO BUILDING PERMIT RUILDIN'GADDRESS: 10555MARYAVE CONT'RACT'OR: .� ,c. _ - PERMITNO: 12070200 OWNER'SNANIB: CI'T'Y OF CUPERTINO su)U�.I� DATE ISSUED:07R60012 OWNER'S PI ION Ii: 9253005318 fl ZONE NO: ❑ LICENSED CONI'RACf0R'S DECLARATION BUILDING PERMIT INFO: BLDG 1- ELECT F- PLUMB F- License Class L.—1.� Lie.a 4D, 41 (� NIECIi r RESIDENTIAL,r CONIDIERCLAL r Contractor POW Z+ — MHvxtUalc � l� I hereby alTirm that 1 am licensed tinder the provisionsof Chaplcr 999 •JOB DESCRIPTION: UPGRADE EXISTING BREAKER FROM 30 T060 AMPS (commencing with Section 7000)of Division 3 of the Business S Professions AND Code and that my license is in full force and effect. UPGRADE EXISTING MAIN BREAKER 1 hereby alfirnn under penalty of perjury one of the following neo declarations: I have laid will maintain a certificate of consent 10 sdf-insure for Worker's Compensation,as provided for by Section 3700 o 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 Section 3700 of the Labor Code,for the performance of the work for which this pemtit is issued. Sq.Ft floor Area: Valuation:$1000 APPLICANT CERT'IFICAT'ION I certify that I have read this application mid state chat the above inl'orntation is AI�\Number.32606052.00 Occupancy'1\pe: 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, PERMIT EXPIRES IF WORK IS NOT STARTED costs,told expenses which may accme against said City in consequence of the granting ofthis permit. Additionally.the applicant understands and will comply WITHIN 180 DAYS OF PERMIT ISSUANCE OR with all non-pointsoure• go an ms per me Cupertino Municipal Code.Section 180 DAYS FROM LAST CALLED INSPECTION. 9.18. Signature Date�[f ?— Issued by: ��N /rJ/«� Date: ❑ OWNER-BUILDER DECLARATION ( '' hereby affirm that I am exempt from Ile Contractor's License Lav fur one of RE-ROOFS: the following too reasons: All roofs shall be inspected prior to any roofing material being installed.Ito root is 1,as owner of the property,or my employees with wages as their sole compensation, installed without first obtaining an inspection,I agree to remove all nese materials for will do the work,and die structure is not intended or offered for sale(Sec.7044- inspection. Business&Professions Code) I,as owner of the property,am exclusively contracting with licensed contractors to Signature of Appli©ne Date. construct the project(Sec.7044,Business d Professions Code). 1 hereby affirm wider penalty of perjury one of the following three ALL ROOF COVF,RINGS T'O BE CLASS"A"OR BI:ITER declarations: I have and will maintain a Certificate of Consent to self-insure for Worker's HAZARDOUS d1AT'ERLU S DISCLOSURE 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 read the hazardous materials requiremens under Chapter 6.95 of the I have and will maintain Worker's Compensation Insurance,as provided for by California Ileahh S Safety Coda Sections 25505,25533,and 25534. 1 will maintain Section 3700 ofthe Labor Code,for the performance oftbe work for which this compliance with the Cupertino Municipal Code.Chapter 9.12 and the Ileahh& Safely Code.Section_553_(x)should I store or handle hazardous material. permit is issued. Additionally,should I use equipment or devices which emit hazardous air I certify that in the performance of the work for which this permit is issued,I shall contaminants as defined by the Bay Area Air Quality Management District 1 will not employ any person in any manner so as to become subject to the Worker's maintain compliance with the Cupertino Municipal Code.Chapter 9.12 and the Compensation laws of California. If,after making this certificate ofexenipcion,I Ileahh.Y Sa ) Code.Sections 25505,25533,and 25534. become subject to the Worker's Compensation provisions of the Labor Code,I must 7 forthwith comply with such provisions or this permit shall be deenmed revoked. Own o it thorizcd agent. Dater APPLICA\I'CERTI FICATTON CONSTRUCTION LENDING AGENCY I cenity that I have read this application and state that the above information is coffee[.1 agree to comply with all city and county ordinances and slate laws relating I hereby affirm that there is a construction lending agency for the performance of work's to building construction,and hereby authorize representatives of this city to enter for which this permit is issued(Sec.3097,Civ C.) upon the above mentioned property for inspection purposes.(We)agree to save Lender's Naar indemnify and keep harmless the City ol'Cupertino against liabilities,judgments• costs•and expenses which may accrue against said City in consequence of the Lender's Address granting of this permit.Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code,Section ARCIIITECT"S DECLARATION 9.18. 1 understand my plans shall be used as public records. Signature Date Licensed Professional CvPmak, -- 12,;LD--7 020 GENERAL PERMIT APPLICATION M E P COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 950143255 M ' SC CUPERTINO (408)77 nc -3228 • FAX (A08)777-3333 • buildinGcuoertino.orG ❑PLUNMINC, ❑,ECHkNTCAL. �61-1:E=CA-L ❑NUSC`LANEOUS PRo,rcT ADDR�s V SS S /'1 A.V ,Q C .APN a Y OWNER�Tt.�✓ OF GU��r'TING 2He(5' 3 eo - 5311�� Ent ^ -- STR.RTADOPece CITY. STATE Z@ FA.Y CONTACT NAME ' PHONE3E-MAIL 1 AI/1 � JA1125 0 - �`I - 3y - S,RZETADDRESS .STAT-. IIP F Y VO\11L O2S z .c+ Lr� v ` iVRvrAbC, ❑OWNER ❑ OWNER-BUIIDM ❑ OWNER AGc?!i ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ AROUTECT. ❑ENGIWEER ❑ DEVELOPER ❑ T--ANT CONTRACTOR NAME CENSE NUMBER LICENSE 7YPE O BUS.LICK Ohl tY— L COMPANY NA.ME 3 ^ O n—NL E-MA.2 FAX 1111M 4 SP.1L'=T AfJORESS Le Cw•�\, �, .5T ooh_ II a., P - 911'-3 � y ARCfifi/ENGNEERANAME LICENSE NUMBER I BUS.LIC U COMPANY NAA E' I E-MAIL FAX STREETADDRESS I CRY,STATE ZIP I PHONE USE OF ❑SFD w DUPLEX ❑ M i-FA.am-Y I PROTECT N W DDU ❑ YES I PROTECT N ❑Y� I IS TILE BLDG AN El BUTLDINO: COMMERCIAL URBAN R+1—iiPEA ACE ARNO FLOOD ZONE ND EICHLFR HOME: O DESC=ON OF WORK L) (5) Y(\ tk,\ti � r I n b-Cbl' L IL n 0^ O to() rvt t TOTAL VALUATION: �� 0 I RECEIVED BY: Hy my signature below,I certify to each of the;alt g: am the prop e-;y owner or=thorized agem to act on the propery owner's behalf. I have read this application and the information I have provided i prrtc f have:rad Lh<Descipdon of Work and verify it is accurate. [agree to comply with all applicable local ordinances and state laws relating to. 'Icli'n ovc' n.-I antborize representatives of Cuoer :c:c entcr the above-idndfiedpropc.--/for inspection purposes. Signamm of ApplicaztdAgnc Dam: '7�:- z 6 1 7--� SUP r AL NFORtM.71ON REQUnUD OFFICE USE ONLY y OVER-THE-COUNTER 's ❑ EYPTtE55 U x ❑ STANDARD U Z ❑ L.ARCE ❑ NIMOR rICPMtscApp_2011.doc revised 06/21/11