11040128CITY OF CUPERTINO BUILDING PERMIT I
BUILDING ADDRESS: 10424 ALICIA CT I CONTRACTOR: _ PERMIT NO: 11040128 I
OWNER'S NAME: ADAMS TERRY G AND NANCY S I�� �S �� DATE ISSUED: 04/19/2011
r- "NER'S PHONE: 4089311012
Li LICENSED CONTRACTOR'S DECLARATION
License Class - ��
Lic. # -1 l k f_'"/1'
4_ V N _ k,
Contractor h E t1JV1bn Date
I hereby affirm that I am licensed under a provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business & Professions
C de and that my license is in full force and effect.
r
f'ber-M 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
Section 3700 of the Labor Code, for the performance of the work for which this
permit is issued.
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
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
costs, and expenses which may accrue against said City in consequence of the
granting of this permit. Additionally, the applicant understands and will comply
with all non -point source regula ' per the Cupertino Municipal Code, Section
9.18. '
D f,
Signa �' Date q I ^ I
OWNER- BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons:
I, as owner of the property, or my employees with wages as their sole compensation,
will do the work, and the structure is not intended or offered for sale (Sec.7044,
Business & Professions Code)
I, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec.7044, Business & Professions Code).
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
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
Section 3700 of the Labor Code, for the performance of the work for which this
permit is issued.
I certify that in the performance of the work for which this permit is issued, I shall
not employ any person in any manner so as to become subject to the Worker's
Compensation laws of California. If, after making this certificate of exemption, I
become subject to the Worker's Compensation provisions of the Labor Code, I must
forthwith comply with such provisions or this permit shall be deemed revoked. 4
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
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
and expenses which may accrue against said City in consequence of the
ng of this permit. Additionally, the applicant understands and will comply
wiin all non -point source regulations per the Cupertino Municipal Code, Section
9.18.
PHONE NO:
BUILDING PERMIT INFO: BLDG ELECT F PLUMB F
MECH F RESIDENTIAL I- COMMERCIAL I-
JOB DESCRIPTION: RELOCATION OF MAIN & SECONDARY SFDWL GAS
MAINS
* *SEE NOTES **
Sq. Ft Floor Area: I Valuation: $4825
APN Number: 34245026.00 1 Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
Issued bps �- = ..__._.�` sLL._ Date:,/-
RE- ROOFS:
All roofs shall be inspected prior to any roofing material being installed. If a roof is
installed without first obtaining an inspection, I agree to remove all new materials for
inspection.
Signature of Applicant: Date:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
HAZARDOUS MATERIALS DISCLOSURE
I have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain
compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health &
Safety Code, Section 25532(a) should I store or handle hazardous material.
Additionally, should I use equipment or devices which emit hazardous air
contaminants as defined by the Bay Area Air Quality Management District I will
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
Health & Safety Code, Sections 25505, 25533, and 25534.
-/I - //
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of work's
for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
Lender's
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Signature Date I Licensed Professional
CUPERTINO
19..1
//()1/0 0
GENERAL PERMIT APPLICATION MEP
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014 -3255 RA' Q
(408) 777 -3228 • FAX (408) 777 -3333 • buildingecupertino.org
I- l XCI-U A XTTr AT n FT F(- TRTCAT. MISCELLANEOUS
PROJECT ADDRESS
APN Y �Z Yo Vp_ 60
1 11A
OWNER NAME d��
G/
� �
PHONE qq
/ZIPS
73 / r I Cl
J(
E Py Gd-mS Av . cbm . ki
STREFTADDRESS
CITY, STATE
FAX
CONTACT NAME
PHONE
E-MAIL
STREET ADDRESS !
CITY, STATE, ZIP
FAX
❑ OWNER ❑ 1( ER- BUILDER
/
❑ OWNERAGENT t CONTRACTOR ❑CONTRACTORAGENT ❑ ARCHrrEcr ❑ ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME t
j
LICENSE NUMBER
4 /l.2 4
/
L ETC
/uw�.H/i.�- C 3�
BUS. LIC k
( In0 �'
C-
COMPANYNAME "2 2
lVV1�b!/1
MAO
E�VeJ
'
�w•6,.1 � c>nwr:��{ -. N�'F
F
��l y'fO —/y0S
STREET ADDRESS
C ZIP
2
Of Z -- OS NE
ARCMTECTIENGINEER NAME
;STATE,
LICENSE R
BUS. LIC 9
COMPANY NAME
E -MAIL
FAX
STREET ADDRESS
CITY, STATE, ZIP
PHONE
1 SFD or Duplex C] Multi - Family
PROJECT IN WTLDLAND
PROJECT IN
ISE OF
AN INTERFACE AREA ❑ Yes ❑ No
FLOOD ZONE ❑ Yes ❑ No
STRUCTURE: ❑ Commercial
DESCRIPTION OF WORK
/
�vc.c *,�1✓.
1)/a r I/, f
@ 6� 14, r7 04
10 7-0
TOTAL VALUATION:
26
By my signature below, I certify to each o e following: I am a property er or authorized agent to act on the property owner's behalf. I have read this
application and the information I have ovided is Corr I ve read the De ription of Work and verify it is accurate. I agree to comply with all applicable local
ctione-
authorize re entatives of
Cupertino to enter the above- identified property for inspection purposes.
ordinances and state laws relating
to , Ilding con
SignaturaofApplicandAgent
Date:
S
PLEMENTAL 10ORMATION
REQ=D
Y �L^EJvU�r.QYfJJiTc �F __ ._
EllI
2L
MEPMisc4pp_2011.doc revised 03116111