B-2016-1230CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS:
CONTRACTOR:
PERMIT NO: B-2016-1230
20316 NORTHBROOK SQ CUPERTINO, CA 95014-0566 (316 39 015)
( BATH FITTER
NORTHERN
CALIFORNIA)
SACRAMENTO, CA
95834
OWNER'S NAME: KOGUT ELIZABETH A TRUSTEE
DATE ISSUED: 01/20/2016
OWNER'S PHONE:
PHONE NO:
LICENSED CONTRACTOR'S DECLARATION
BUILDING PERMIT INFO:
7.License Class Lie. # 9j`5
Contractor ( BATH FITTER NORTHERN CALIFORNIA) Date
X BLDG _ELECT X PLUMB
MECH X RESIDENTIAL COMMERCIAL
I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing
_
with Section 7000) of Division 3 of the Business & Professions Code and that my
license is in full force and effect.
JOB DESCRIPTION:
Remove and replace shower valve.
I hereby affirm under penalty of perjury one of the following two declarations:
1. 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
Sq. Ft Floor Area:
Valuation: $1000.00
this permit is issued.
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above
PN Number:
Occupancy Type:
information is correct. I agree to comply with all city and county
316 39 015
316
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
PERMIT EXPIRES IF WORK IS NOT STARTED
expenses which may accrue against said City in consequence of the
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
granting of this permit.A tionally, the applicant understands and will
comply with all n n-pQ t sourc regulations per the Cupertino Municipal
180 DAYS FROM LAST CALLED INSPECTION.
Code, Section 9.
`Signature (�1 Date j
Issued by:
Date:
OWNER -BUILDER DECLARATION
RE -ROOFS:
I hereby affirm that I am exempt from the Contractor's License Law for one of the
All roofs shall be inspected prior to any roofing material being installed. If a roof is
following two reasons:
installed without first obtaining an inspection, I agree to remove all new materials for
1. I, as owner of the property, or my employees with wages as their sole
inspection.
compensation, will do the work, and the structure is not intended or offered
for sale (See.7044, Business & Professions Code)
Signature of Applicant:
2. I, as owner of the property, am exclusively contracting with licensed
Date:
contractors to construct the project (Sec.7044, Business & Professions Code).
I hereby affirm under penalty of perjury one of the following three declarations:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
1. 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
HAZARDOUS MATERIALS DISCLOSURE
performance of the work for which this permit is issued.
I have read the hazardous materials requirements under Chapter 6.95 of the
2. I have and will maintain Worker's Compensation Insurance, as provided for
California Health & Safety Code, Sections 25505, 25533, and 25534. I will
by Section 3700 of the Labor Code, for the performance of the work for which
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
this permit is issued.
Health & Safety Code, Section 25532(a) should I store or handle hazardous
a. I certify that in the performance of the work for which this permit is issued, I
material. Additionally, should I use equipme or devices which emit hazardous
shall not employ any person in any manner so as to become subject to the
air contaminants as defined by the Bay Ar uality Management District I
will maintain compliance with the cipal Code, Chapter 9.12 and
Worker's Compensation laws of California. If, after making this certificate of
the Health & Safety Cod ,Specx25533, and 25534.
exemption, I become subject to the Worker's Compensation provisions of the
e's
Labor Code, I must forthwith comply with such provisions or this permit sh hl
caner or authorised agent: /
be deemed revoked.
Date:
L �✓��CONSTRLTCTION 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
correct. I agree to comply with all city and county ordinances and state laws
of work's for which this permit is issued (Sec. 3097, Civ C.)
relating to building construction, and hereby authorize representatives of this city
Lender's (dame
to enter upon the above mentioned property for inspection purposes. (We) agree
to save indemnify and keep harmless the City of Cupertino against liabilities,
Lender's Address
judgments, costs, and expenses which may accrue against said City in
ARCHITECT'S DECLARATION
consequence of the granting of this permit. Additionally, the applicant
understands and will comply with all non -point source regulations per the
I understand my plans shall be used as public records.
Cupertino Municipal Code, Section 9.18.
Licensed
CUPERTINO I
GENERAL PERMIT APPLICATION MEP
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
40300 TORRE AVENUE • CUPERTfNO, CA 95014-3255 M
'
(408) 777-3228 • FAX (408) 777-3333 buildingft— upertino.orq j� .�Dlh ,%a3� S C
STREET ADDRE S C STATE, ZIP FAX
;Dos6v,v SQ�, r
r.nWTACT NAMJi _ P111.7 F T,TATT
ZIP
I❑ OWNER ❑ OWNER -BUILDER ❑ -OWNER AGENT K CONTRACTOR ❑ CONTRACTOR AGENT j❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT I
CQNU ACTOR t4AT413 LICENSE NUMBER I LICENSE TYPE
STR D
AJC PLUMBING UMECHANICAL
UELECTRICAL
❑MISCELLANEOUS
40 ADDS
- - O
LICENSE NUMBER
APN #
OjWFR NAME
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PHpNE _ ^ y� �,
EMAIL
STREET ADDRE S C STATE, ZIP FAX
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r.nWTACT NAMJi _ P111.7 F T,TATT
ZIP
I❑ OWNER ❑ OWNER -BUILDER ❑ -OWNER AGENT K CONTRACTOR ❑ CONTRACTOR AGENT j❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT I
CQNU ACTOR t4AT413 LICENSE NUMBER I LICENSE TYPE
STR D
CITY, STATE, ZIP ,
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ARCHITECT/ENGINEER NAME
LICENSE NUMBER
BUS. LIC #
COMPANY NAME
E-MAIL
FAX
STREET ADDRESS
CITY, STATE, ZIP.
PHONE
USE OF JR SFD or DUPLEX ❑ MULTI -FAMILY
BUILDING: [3 COMMERCIAL
PROJECT IN WILDLAND ❑ YES
URBAN INTERFACE AREA O
PROJECT IN ❑ YES
FLOOD ZONE
IS TILE BLDG AN ❑ YES
EICHLER HOME? NO
DESCRIPTION OF WORK
l \O p/
TOTAL VALUATION: I (�
RECEIVED BY:.'
By my signature below, I certifytoeach of th o ing: I m the property owner or authorized agent to act on the property owner's behalf. I have read this
application and the information I have provi disc rect. ave read the Description of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating to build' const Ie ' I. I authorize representatives of Cupertino to enter the above -identified property for inspection purposes.
Signature of Applicant/Agent- Date: QA
ME AL INFORMATION REQUIRED
oFFcE USE'ONLY
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OVER THE -COUNTER
I� EXPRESS •,.
❑ STANDARD
V
`❑ LARGE
'� MAJOR
MEPMiscApp 2011.doc revised 06/21/11
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS:
20316 NORTHBROOK SQ CUPERTINO, CA 95014-0566 (316 39 015)
CONTRACTOR:
( BATH FITTER
NORTHERN
CALIFORNIA )
SACRAMENTO, CA
95834
PERMIT NO: B-2016-1230
OWNER'S NAME: KOGUT ELIZABETH A TRUSTEE DATE ISSUED: 01/20/2016
OWNER'S PHONE: PHONE NO:
LICENSED CONTRACTOR'S DECLARATION
License Class Lic. #
Contractor ( BATH FITTER NORTHERN CALIFORNIA ) Date
I hereby affirm that I am licensed under the provisions of Chapter 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:
1.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.
2.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 regulations per the Cupertino Municipal
Code, Section 9.18.
Signature___________________________________ Date
OWNER - BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor’s License Law for one of the
following two reasons:
1.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)
2.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:
1.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.
2.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.
3.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.
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 regulations per the
Cupertino Municipal Code, Section 9.18.
BUILDING PERMIT INFO:
X BLDG ELECT X PLUMB
MECH X RESIDENTIAL COMMERCIAL
JOB DESCRIPTION:
Remove and replace shower valve.
Sq. Ft Floor Area: Valuation: $1000.00
APN Number:
316 39 015
Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
Issued by: 1421
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.
Owner or authorized agent: ________________________________
Date:
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 Address
ARCHITECT’S DECLARATION
I understand my plans shall be used as public records.
Licensed
Signature___________________________________ Date Professional________________________________________________