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10010064 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10555 MARY AVE CONTRACTOR:ELCOR ELECTRIC,INC. PERMIT NO: 10010064 OWNER'S NAME: CITY OF CUPERTINO 3310 BASSETT ST DATE ISSUED:01/14/2010 TER'S PHONE: 4087773272 SANTA CLARA,CA 95054 PHONE NO:(408)986-1320 ❑ LICENSED CONTRACTOR'S DECLARATIONF_ BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class Lic.# MECH F RESIDENTIAL COMMERCIAL Contractor Date I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:INSTALL ELECT PANEL,DISCONNECTS,WIRING& (commencing with Section 7000)of Division 3 of the Business&Professions OUTLETS Code and that my license is in full force and effect. TO FEED SELF CONTAINED POWER WASHING STATION 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:$25000 permit is issued. APPLICANT CERTIFICATION APN Number:32606052.01 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 _ �� Date:./, Signature Date •cam 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 r r authorized a t: forthwith comply with such provisions or this permit shall be deemed revoked. �'�°� Date: CONSTRUCTION LENDING AGENCY APPLICANT CERTIFICATION 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 it -nnify and keep harmless the City of Cupertino against liabilities,judgments, Lender's Address and expenses which may accrue against said City in consequence of the g,mng of this permit.Additionally,the applicant understands and will comply ARCHITECT'S DECLARATION with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. I understand my plans shall be used as public records. n I Signature k Date jll O Licensed Professional stm, CITY OF CUPERTINO CU CITY E OF GENERAL BUILDING � PERMIT APPLICATION FORM APN# Date: / Building Address: /055-S /11)9 2 Mailing Address (if different from budding address): S4 r"7 e Are Hazardous Materials being used as part of this project? Yes ❑ No;�[ HOA: (Exterior work only) Yes ❑ No ❑ If yes, provide letter from HOA Owner's Name: Phone#: - c l� D f CO 7 O 7 3 Z7 .Z Contractor: Phone: 5 4-0/? Elec Fax: 4/0(f • `/(f 6 /3 o Contractor License#: -TO 0 dt 2 e Cupertino Business License#: Contact: Phone: 7 7 �� 3 Fax: �/ 7 Residential ❑ Commercial Job Description: y iu s 14 N / llef c,q r3 tie- 1 , of IS e o N t /4.,-,a,( cP e---/le/-j-, jo 4 eeo/ s 4e llr CC�^J -14/"-j e C:1 Cr-'2 Building Permit Info: Bldg ❑ Elect Plumb ❑ Mech ❑ Type of Construction (Usage Class): Occupancy Type: 1-A, 1-B ❑ II/III/V-A ❑ II/III B. IV-HT, V-B 20""' . Valuation: Square Footage: aS avv N�� J Project Size: ExpressO Standard I--] Large F] Major El Green Building: Please complete relevant portion of the Green Building/LEED Checklist& attach it to the application or if applicable, include in plan set& the sheet index. Points Achieved: For help, contact Build it Green at www.buflditgreen.org Revised 07/14/09 Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone(408)777-3228 Fax(408)777-3333 CITY�F -7UPEkTINO ' &Y7 Dearum a ret Buildin OB ADDRESS: ERMIT # J //��C� G��'( �a sss R OWNER'S NAME: Ct& C" et Alamo PHONE # 77 7-3�-� Z GENERAL CONTRACTO : �lc� �le� IFAX# 7 77- 3 3 477 I am not using any subcontractors: Date Signature Please check applicable subcontractors and complete the following information: -a FSUB CONTRA CTOR BUSINESS NAME BUSINESS LICENSE # Cabinets &Millwork Cement Finishing Electrical le c Excavation Fencing : Floorin g• Carpeting Linoleum/ Wood Glass / Glazing Heating Insulation Landscaping Lathing Masonry Ornamental Sheet Metal Painting/ Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile Date retractor Signature