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14070145 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 20955 STEVENS CREEK BLVD CONTRACTOR:MISSION ELECTRIC PERMIT NO: 14070145 COMPANY OWNER'S NAME: WEISS PAUL E AND BARBARA H TRUSTEE 5700 BOSCELL CMN DATE ISSUED:07/31/2014 OWNER'S PHONE: 4082577000 FREMONT,CA 94538-5111 PHONE NO:(510)657-4460 LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL COMMERCIAL ❑ INSTALL 5(N)DEDICATED CIRCUITS&5(N)CORD REEL LicenseClass `I Li,—# DROPS FOR FUTURE REFRIGERATED UNITS 1�0Contractor Date1 I hereby affirm that I am licensed under the provisions f apter 9 (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's Compensation,as provided for by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. Sq.Ft Floor Area: Valuation:$20000 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 APN Number:32631022.00 Occupancy Type: permit is issued. APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED correct.I agree to comply with all city and county ordinances and state laws relating WITHIN 180 DAYS OF PERMIT ISSUANCE OR to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We)agree to saveng F CALLED INSPECTION. 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 co Date: oo with all non-poi ource r I io s er the Cupertino Municipal Code,Section 9 18. 1 RE-ROOFS: Signature Date ected prior to any roofing material being installed.If a roof is obtaining an inspection,I agree to remove all new materials for p . ❑ OWNER-BUILDER DECLARATION Signature of Applicant: Date I hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER 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 HAZARDOUS MATERIALS DISCLOSURE construct the project(Sec.7044,Business&Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the California Health&Safety Code,Sections 25505,25533,and 25534. I will I hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the declarations: Health&Safety Code,Section 25532(a)should I store or handle hazardous I have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally,should I use equipment or devices which emit hazardous Compensation,as provided for by Section 3700 of the Labor Code,for the air contaminants as defined by the Bay Area Air Quality Management District I performance of the work for which this permit is issued. will maintain compliance with the upertiok3, i i 1 Code,Chapter 9.12 and I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Se 5 a d 5534. performance of the work for which t Section 3700 of the Labor Code,for the his p Owner or authorized agent: Date: 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 CONSTRUCTION LENDING AGENCY become subject to the Worker's Compensation provisions of the Labor Code,I must I hereby affirm that there is a construction lending agency for the performance of forthwith comply with such provisions or this permit shall be deemed revoked. work's for which this permit is issued(Sec.3097,Civ C) Lender's Name APPLICANT CERTIFICATION Lender's Address 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 ARCHITECT'S DECLARATION indemnify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records. granting of this permit.Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code,Section Licensed Professional 9 18. Signature Date GENERAL PERMIT APPLICATION ELI] COMMUNITY DEVELOPMENT DEPART ` MEP MENT BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO,CA 95014-3255 O� CUPERTINO (408)777-3228-FAX(408)777-3333•building(akupertino.ora �� MISC PLUMBING DINECHANICAL PrELECTRICAL ONUSCELLANEOUS PROJECT ADDRESS y� O l J APN# 7 / 3 / Q 2-- OWNERNAME Q�� %— CONTACT [ �STREET ADDRESS PI+v1— A145;�5SCITY,STTATTE,ZIPFAX NAW - j o 1 PHONE v�9- `1''f 9 STREET ADDRESS CITY,STATE,ZIP FAX ❑OWNER ❑OWNERBUILDER ❑owNERAGENT ❑ CONTRACTOR ❑CUNTRACrORAGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT CONTRACTOR NAME ` ' ` s LICENSE N(!�E LI E BUS.LIC# COMPANY NAME l Ss t _ E-MAIL FAX STREET ADDRESS fl �Jl 1' CITY,STATE,ZIP PHo I� > , ARCHIIECT/ENGIIJEERNRME LICENSE NUMBER BUS.LIC# COMPANY NAME E-MAIL. FAX STREET ADDRESS CITY,STATE,ZIP PHONE USE OF ❑SFD o DUPLEX ❑ MULT7 FAmmy PROJECT IN WE.DLAND ❑ YES PROJECT IN ❑YES IS THE BLDG AN ❑yES BUILDING: ❑COWAERCIAL URBAN INTERFACE AREA ❑ NO FLOODZONE ❑NO EICHLERHOMFi7 ❑NO DESCRIPTION OF WORK 1 t...v TOTAL VALUATION: ✓J i►^t By my signature below,I certify to each of the following: the property owner or authorized agent to act on the prop have read this et application and the information I v d s t e read the Description of Work and verify it is accurate, gree to comply with all applicable local ordinances and state laws relatin I orize representatives of Cupertino to enter thea ve-i 9tifr property for inspection purposes. Signature of Applicant/Agent: Date: 1 SUPPLEMENTAL INFORMATION REQUIRED OFFICE USE ONLY W ❑ OVER-THE-COUNTER ❑ EXPRESS ❑ STANDARD U ❑ LARGE a ❑ MAJOR MEPMiscApp_2011.doc revised 06/21/11 2-0/ Ca P oRTINO ePartnent COMMUNITY DEVELOPMENT DEPARTMENT RE1/�EINE BUILDING DIVISION-CUPERTINO °'SUR CO APPROVED ey °E con�pt..�A�cr APPROVE * This set of plans and specifications MUST be kept at the job s.ite<during construction. It is unlawful to make any dhang 7s or alterations on same,or to deviate the,efro'n,wi'ihout approval from the Building Official. Th: z rr?")inq of this plan and specifications SHALL NOT x bp rmit or to be an approval of the violation ak C „y ;o s Ordinance or State Law. ',� , A .� VU �p1 IZo1Zc�3 V YfiN 16a'sA 2"cx o Vo' I,* gel 'Z-M' s c�J) 2-SA I T©ice !t S Y i .. I ��.�.� ,�� _: _�-�, ► wax ♦ > '��' 1 . i \ I —_— - . _ gill . _ ................. F ho i '•. 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