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B-2016-1439 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: CONTRACTOR; PERMIT NO:B-2016-1439 10701 BAXTER AVE CUPERTINO,'CA 95014(326 11 092) (J T R.PLUMBING) GILROY,CA 95020 OWNER'S NAME: TANG LYNN YAND WANG PAINING DATE ISSUED:02/26/2016 OWNER'S PHONE:. PHONE NO:408-858-1274 -LICENSEDID A BUILDING PERMIT INFO: License Class Lic.# Contractor(J T R PLUMBING).Date�._; ,� r�„� X BLDG ' ELECT X PLUMB I hereby affirm that I am licensed under the provisions of Chapter 9(commencing MECH X RESIDENTIAL_COMMERCIAL with Section 7000)of Division 3 of the Business&Professions Code and that my license is in full force and effect. JOB DESCRIPTION: I hereby affirm'under,penalty of perjury one of the following two declarations: INSTALL NEW GAS LINE FROM METER TO RANGE.. i. 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. z 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. Sq.Ft Floor Area: Valuation:$1500.00 APPLICANT CERTIFICATION certify that I have read this application and state that the above - information is correct.I agree to comply with all city and county APN Number: Occupancy Type:: ordinances and state laws relating to building construction,and hereby 326 11 092 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. Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal 180 DAYS FROM LAST CALLED INSPECTION. Code,Section 9.18. , \ .244 Issued by:Phuong Devries Signature" ' Date '~ ..: 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(Sce.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. 1 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(x)should I store or handle hazardous a. 1 certify that in the performance of the work for which this permit is issued,I material. Additionally,should I use equipment 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 Area Air Quality Management District I will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and Worker's Compensation laws of California. If,after making this certificate of the Health&Safety Code,Sections 25505,25533,and 25534. 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 Owner or authorized agent: be deemed revoked. Alate: J/ APPLICANT CERTIFICATION ON TRUCTION 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 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 Name 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 Professional Signature Date t.' GENERAL PERMIT APPLICATION MEP COMMUNITY DEVELOPMENT DEPARTMENT BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO,CA 95014-3255 CUPERTINA (408)777-3228•FAX(408)777-3333•buildin-gQ-cupertino.ong MISC PLUMBING ❑MECHANICAL ,QELECTwAL ❑MISCELLANEOUS PROJECT ADDRESS 0 L AAPN# 2 -VAC �Y t' ' 11 OWNER NAME �A —} !st ,VA 14 A Ka f PHONE E-MAIL STREET ADDRESS CITY, STATE;ZIP FAX �.e �Vfm CONTACT NAME %VI� 1 on PHONEN�� (�C [a-77 L EMAIL STREET ADDRESS v Y " CITY,STATE,ZIP �j / PA}{ ❑OWNER ❑ OA'NTER-B ,❑^OWNERAGENT V,.GONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGIN>EER.. ❑ DEVELOPER ❑TENANT CONTRACTOR NAME Z:n� Y 1 LICENSE NUMBER G c j I Fj �r} 3 LICENSE TYPE/' / BUS.LIC# COMPANY NAME E-MAIL `'�� {( ©J`�(� o ( , U Kp �1,M) 1I . - FAX Ve STREET ADDRESS6 G1_, 7]] �S (j �– CITY,STATE,ZIP(3"' L ARCHITECT/ENGINEER NAME 1� SVD" LICENSENUMBER vL d /J BUS.LIC# J 11 COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE USE OF FD or DUPLEX ❑ MULTI-FAMILY PROJECT IN WILDLAND ❑ YES PROJECT IN ❑YES IS THE BLDG AN ❑YES BUILDING: ❑COMMERCIAL URBAN INTERFACE AREA ❑.NO FLOOD ZONE ❑NO EICHLERHOME? ❑ NO DESCRIPTION OF WORK Ale V DOTAL VALUATION: RECEIVEDB ... By my signature below,I ce 'fy to each of the following: I am the property owner or authorized agent to act on the pro e o er's behalf. I have read this application and the information I have prov' d is correct have read the Description of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating to b ding co cf I authorize representatives of Cupertino to enter the above-identified property for inspection purposes. Signature of Applicant/Agent. Date: SUPPLEMENTAL INFORMATION REQUIRED � fl�fly ER THE COIJN'I'ER r. s<" D EXPRESS U y � r❑ ]lRAJOR' � MEPMisc,4pp_2011.docrevised 06121111