12100042 CITY OF CUPERTINO BUILDING PERMIT
RUILDING ADDRESS: 21929OAKDELL PL CONTRACTOR:BENAVENTE PLUMBING PERMIT NO: 12100042
OWNF,R'SNAM E: CHANDLER TINIOT1'IY R.P AND ZAMOONNA 305 SANANI'ONIO CT APT3106 DA'Z'E ISSUED: 10/052012
OWNER'S PIIONF,: 6508772337 SAN JOSE.CA 95116 PHONE NO:4408)712-7071
0) LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT r PLUMB I-
License Class'C3=4�-Lic..N 50 1
AIECH r RESIDENTIAL I- COMMERCIAL(-
Contmetor. n/ L r_t� Date 10 -
�"" ` " -- - JOB DESCRIPTION:REPLACE EXISTINGGAS LINE WITH I INCHGAS LINETO
hereby allir hal I am licensed under the provisions of Chapter 9 314 INCH THROUGHOUT
(commencing with Section 7000)of Division 3 of the Business& Professions
Code and that my license is in full force and effect.
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[he 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:$875
Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued.
APN Number:'32639001.00 Occupancy T)PC:
,\I'PI,ICANI'CF,R'1'IFICA'1'ION
I certify that I have read this application and slate dial 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 PERMIT EXPIRES IF WORK IS NOT STARTED
upon the above mentioned property for inspection purposes. (We)agree to save
indemnify and keep harmless the City of Cupertino against liabilities.judgments, WITHIN 180 DAYS OF PERMIT ISSUANCE OR
costs,and expenses which may accrue against said City in consequence of the 180 DAYS FROM LAST LLEp INSPECTION.
granting ofthis permit. Additionally,the applicit understands and will comply
with all non-point sourer regulatuls per the .,"ino Municipal Code,Section
9.18• Issued by: `/" le:
Signatuc - iL Date' - _ /-•rZ
❑ OWNER-BUILDER DECLARATION RF:ROOFS:
All roofs shall be inspected prior to any roofing material being installed.If a roof is
I hereby affirm that I am exempt from the Contractor's License Law for one of installed without first obtaining an inspection,I agree to remove all new materials for
the following two reasons: inspection.
I,as owner of the property,or my enhployces with wages as their sole compensation,
will do the work,and the structure is not intended or offered for sale(Sec.7044. Signature of Applicant: Date:
Business&Professions Code)
I,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business& Professions Code). ALL ROOF CO\'I[RINCS'f013E CLASS"A"Oil 131i'I'1'IiR
I hereby affimn under penalty of perjury ane of the following three
declarations: HAZARDOUS\IA'I'l?RIALS DISCLOSIIRI;
I have and will maintain a Certificate ofConsenl to self-insure for Worker's I have read the hazardous materials requirements under Chapter 6.95 of the
Compensation,as provided for by Section 3700 of the Labor Code,for the California I Iealth&Safety Code,Sections 25505,25533,and 25534. 1 will mainmin
performance of the work for which this permit is issued. compliance with the Cupertino Municipal Code,Chapter 9.12 and the I Iealth&
I have and will maintain Worker's Compensation Insurance,as provided for by Safetv Code.Section 25532(a)should I store or handle hazardous material.
Section 3700 of the Labor Code,for the performance of the work for which this Additionally,should I use equipment or dc%ices e'hich emit luhzardous air
contaminants as defined by the Boy Area Air Quality Management District I will
permit is issued maintain compliance with the Cupertino Municipal Code.Chapter 9.12 and the
I certify that in the performance of the work for which this permit is issued.I shall Dealih&Safety Code,Sections 25505.25533,and 25534.
not employ any person in any manner so as to become subject to the Worker's
Compensation lass of California. If,after making this certificate of exemption,I Oen r or au --e
become subject to the Worker's Compensation provisions of the Labor Code,I must Ilite:OG/_=
forthwith comply with such provisions or this permit shall be deemed revoked. —�
CONSTRUCTION LENDING AGENCY
APPLICANT CER'TI FICATION I hereby affirm that there is a construction lending agency for the performance of work's
I certify that I have read[his application and state that the above infomm[ion is for which this permit is issued(Sec.3097,Civ C.)
correct.I agree to comply with all city and county ordinances and state laws relating Lender's Name
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes.(We)agree to save Lender's Address
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the ARCIIITEC`I"S DECLARATION
granting of this permit.Additionally,the applicant understands and will comply
with all non-point source regulations tier the Cupertino Municipal Code.Section 1 understand my plans shall be used as public records.
9.18.
Licensed Professional
Signature Dalc D�� Z
Strong Motion Fee: $0.00 Select an Administrative/Item
131c1e Stds Commission Fee: $0.00
F
IZ ( 0Uv � Z
GENERAL PERMIT APPLICATION M E r
COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION
10300 TORRE AVENUE •CUPERTINO, CA 95014-3255 M
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CUPERTINO (408)777-3228• FAX(408)777-3333 • buildinorMcuoedino.oro
LL-MBING ❑MECHANICAL ❑ELECTRICAL ❑MISC/cZIA,-IEOUS
PROIEC7 ADDRESS / C e / I APN# o/oma 1
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OWNER NAEMAI �GG.arnp/ `GiV Ke-e+�� • e �
STREET ADDRESS G` / CITY, STATE FAX
IIP - ey �a CH /56 I FA
CONTACT NAME E-MAII.
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STREET ADDRESS CITY,STATE ffi FAX
.OWNER ❑ OWNER-BUDDER ❑ OWNER AGENT ❑ CONTRACTOR ❑CONTRACIDRAGEHT ❑ ARCI-DT_C! ❑S'GINMER ❑ DEVELO?Ek ❑ TENANT
HORN LC E� LI(— E BUS.LIC; 3330
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A,NY E-MAIL '/ FAX
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STREADDRESS �• 2 HON
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ARCHITECT/ENGWEER NAME J
LICENSE NUMBER I BUS.LICA
COMPANYNAME' I E-MAD. FAX
STRFcTADDRESS I CITY,STAT-E PHONE
USE OF ❑SM a DUPLEX ❑ MULTI-FAMILY PROJECT M wI DLANO ❑ YES; PROJECT W ❑YES I IS THE BLDG AN ❑ YFS
BUILDING:. []COMMERCLAL URBAN D.TcRFACEAREA ❑ NO FIMDZONE ❑NO SCILOt HOME? ❑NO
DESCRIPTION OF WORKp,
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-76
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TOTAL VALUATION: :.0 RECEIVED BY:
By my signature below,I certify to each of the following: I am elle property owner or authorized agent to act an the property owner's behalf. I have tend this
application and the information I have provided is COM_CL I have read the Description of Work and vestry it is accurate. I ag. -,a comply with all applicable local
o:dinmces aid state laws relating to building constmction. I authorize representatives of Cupemao to enter the above-idenuacd pmpeey for inspection puiposes.
Signace of Applicact/Agen[ Dam:
SUPPLEMENTAL INFORMATION REQUIRED OFFICE USE ONLY
P ❑ OVER-THE-COUNTER
Y
- ❑ EXPRESS
U
J ❑ STANDARD
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Cl LARGE
❑ MAJOR
MEP.Vua4pp_201 J.doc revised 06/21/11