11060148 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 8157 HYANNISPORT DR CONTRACTOR:SOUTHWEST ELECTRIC PERMIT NO: 11060148
OWNER'S NAME: JACK WONG 14510 BIG BASIN WAY DATE ISSUED:06/17/2011
O"'NER'S PHONE: 4083525677 SARATOGA,CA 95070 PHONE NO:(408)999-8721
Li LICENSED CONTRACTOR'S DECLARATIONF
BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class —14 Lic.#
MECH RESIDENTIAL COMMERCIAL
Contractor Date 1
I hereby a at I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:200AMP SERVICE UPGRADE
(commencing with Section 7000)of Division 3 of the Business&Professions
Code and that my license is in full force and effect.
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 Qu
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:$2750
Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued.
APPLICANT CERTIFICATION APN Number:35611020.00 Occupancy Type:
1 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 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 CALLED INSPECTION.
granting of this permit. Additionally,the applicant understands and will comply
with all non-poi o e regulations per the Cupertino Municipal Code,Section
9.18.
-} t Issued b_ . Date:
Signature Date
OWNER-BUILDER DECLARATION RE-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.
1,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, 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 COVERINGS TO BE CLASS"A"OR BETTER
I hereby affirm under penalty of perjury one of the following three
declarations: HAZARDOUS MATERIALS DISCLOSURE
1 have and will maintain a Certificate of Consent 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 Health&Safety Code,Sections 25505,25533,and 25534. I will maintain
performance of the work for which this permit is issued. compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
I have and will maintain Worker's Compensation Insurance,as provided for by Safety 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 devices which emit hazardous air
permit is issued. contaminants as defined by the Bay Area Air Quality Management District I will
maintain c pliance 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 Health fety Code,Sections 25505,25533,and 25534.
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 Owne thorized agent: /
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.
Pl� CONSTRUCTION LENDING AGENCY
APPLICANT CERTIFICATION IIhereby affirm that there is a construction lending agency for the performance of work's
1 certify that I have read this application and state that the above information 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,
r and expenses which may accrue against said City in consequence of the
ag of this permit.Additionally,the applicant understands and will comply ARCHITECT'S DECLARATION
w.,a all non-point source regulations per the Cupertino Municipal Code,Section I understand my plans shall be used as public records.
9.18.
Licensed Professional
Signature Date
GENERAL PERMIT APPLICATION UEP
COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION
10300 TORRE AVENUE- CUPERTINO, CA 95014-3255
CL1FERT1NC3 (408)777-3228 • FAX(408)777-3333 •building acupertino.org misc
❑PLUMBING ❑MECHANICAL ❑ELECTRICAL ❑MISCELLANEOUS
PROJECTADDRESS ' �� O Y APN#17
� �, y
OWNER NAMELj PHONE _ �'
E-MAII
Z r o.ribG &4
STREET ADDRESS CITY,STATE,ZIP FAX
CONTACT NAME1 E-MAIL
T 4Sr it-m'1-101 `„(' 4 czTY srATr; zzP
�f SV 7 FA,a O
❑OWNER ❑ OWNER-80LOER ❑ OWNER AGENT CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ OElELOPER ❑TENANT
CO CT R NAME LICENSE NUMBER LICENSE TYPE B LIC M
CO N g MA L
STREET ADDS S ;. a A\ ,STATE,
�S Wo
ARCHII'ECTIENGINEER NAME LICENSE NUMBER BUS.LIC!f
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
E OF FD or Duplex ❑ Multi-Family PROJECT IN WILDLAND PROJECT IN
j TRUCTURE: ❑ Commercial URBAN INTERFACE AREA Cl Yes ❑ NO FLOOD ZONE ❑ Yes ❑ NO
DESCRIPTION OF WORK
r p
TOTAL VALUATION:
By my signature below,I certify to each of the f wing: I am the property owner or authorized agent to act an the property owner's behalf. I have read this
application and the information I have prov' 4 correct I have read the Des an verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating to buil a representatives of Cupertino to enter the above-identified roQerty for inspection purposes.
Signature of Applicant(Agent: Date:
IENTAL INFORMATION REQUIRED
RM
W &EFMrsaA 2011.doc revised 03/16/11