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11040216 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 22601 VOSS AVE CONTRACTOR:CITY OF CUPERTINO PERMIT NO: 11040216 OWNER'S NAME: CITY OF CUPERTINO 22601 VOSS AVE DATE ISSUED:04/28/2011 OV"'ER'S PHONE: 4087773407 CUPERTINO,CA 95014-5073 PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATIONr BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class Lic.# MECH RESIDENTIAL COMMERCIAL Contractor Date 1 hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:RE-PLUMBING,REMOVE EXISTING GALVANIZED PIPING (commencing with Section 7000)of Division 3 of the Business&Professions & Code and that my license is in full force and effect. REPLACE WITH COPPER APPROX 250SQ'WATER SUPPLY 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 Section 3700 of the Labor Code,for the performance of the work for which this Sq.Ft Floor Area: Valuation:$100 permit is issued. APPLICANT CERTIFICATION APN Number:34215038.00 Occupancy Type: 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 harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City in consequence of the ' WITHIN 180 DAYS OF PERMIT ISSUANCE OR granting of this permit. Additionally,the applicant understands and will comply 180 DAYS FROM LAST CALLED INSPECTION. with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. Issued bp-- G'�'��`�— Date: Signature Date A OWNER-BUILDER DECLARATION RE-ROOFS: I hereby 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: I,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: HAZARDOUS MATERIALS DISCLOSURE 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 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. I 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,I shall maintain compliance 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&Safety Code,Sections 25505,25533,and 25534. 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 Ow er or a thorized agent:.;'% forthwith comply with such provisions or this permit shall be deemed revoked.,�� 9� Date: APPLICANT CERTIFICATION CONSTRUCTION LENDING AGENCY I certify that I 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.I 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 co, ?nd expenses which may accrue against said City in consequence of the gk 3 of this permit.Additionally,the applicant understands and will comply ARCHITECT'S DECLARATION witn all non-point source regulations per the Cupertino Municipal Code,Section 9.18. 1 understand my plans shall be used as public records. t Signature Date dd' Licensed Professional oz-1 GENERAL PERMIT APPLICATION MEP COMMUNITY DEVELOPMENT DEPARTMENT- BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 Lo (408)777-3228• FAX(408)777-3333-building-5cupertino.org MISC CUPERTINU PLUMBING ❑MECHANICAL ❑ELECTRICAL ❑MISCELLANEOUS APN# PROJECT ADDRESS l�2 Q voss r.5 / OWNER NAME PHONEE-MAII� 4 E� / 'J107 STREET ADDRESS CITY,STATE,ZIP FAX CONTACT NAME nF7n W/ PHONE �.. _ D^J GE MAII. 7:ncl/`J `v (1v2 Yl STREET ADDRESS/G)�O() � ? ' FAX 77 7-3>jZIPT ?17 CTTY,? E � ❑OWNER ❑ OWNER-BUILDER '0010WNER AGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT CONTRACTOR NAME // LICENSE NUp4BR _ LICENSE TYPE BUS.LIC# U /"(�/L"-7A z L- (v ?. COMPANY NAMEO C / Pi/�j� /�/N qE-MAIl FAX V ? C 6 p r STREET ADDRESS /C CITY,STATE,ZIP PHONE J A zc G� � c� "/GO- -- 3s -sy ARCHTTECT/ENGINEER NAME LICENSE NUMBER BUS.LIC# COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE 1SE OF ❑ SF,�or Duplex ❑ Multi-Family PROJECT IN WILDLAND PROJECT IN STRUCTURE: p'Commercial URBAN INTERFACE AREA El ❑ No FLOOD ZONE C3 Yes C3 NO DESCRIPTION OF WORK ' /S /ren / P 11 r, P V w,/A lel � a TOTAL VALUATION: ti `RECEIf[EIxB1' * r� r E By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on the property owner's behalf. I have read this application and the information I have provided is correct. I have read the Descripti f Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating to b Ming construction. I authves of Cupertino to enter the abovee--i/de 'feed pr perty for inspection purposes. orize rep s Signature of Applicant/Agent: Date: SUPPLEMENTAL INFORMATION REQUIRED -1111-7A WR MEPMiscApp 2011.doc revised 03/16/11