B-2016-1457 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2016-1457
20590 SHADY OAK IN CUPERTINO,CA 95014-0454(323 44 037) (TRIPLE A PLUMBING
SERVICES LET STINKY
DO IT CORP)
SANTA CLARA,CA
95054
OWNER'S NAME: CHONG FAY JR AND EDITH S TRUSTEE DATE ISSUED:03/02/2016
OWNER'S PHONE:408-661-6833 PHONE NO:408-661-6833
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class C-36 Lic.#943638
Contractor(TRIPLE A PLUMBING SERVICES LET STINKY DO IT CORP)Date X BLDG —ELECT X PLUMB
3/2/2016 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 JOB DESCRIPTION:
license is in full force and effect. 15 FT OF GAS LINE REPAIR
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
r Compensation,as provided for by Section 3700 of the Labor Code,for the
`7 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 Sq.Ft Floor Area: Valuation:$3800.00
this permit is issued.
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above ATN Number:. Occupancy Type:'
information is correct.I agree to comply with all city and county 323 44 037
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 PERMIT EXPIRES IF WORK IS NOT STARTED
harmless the City of Cupertino against liabilities,judgments,costs,and WITHIN 180 DAYS OF PERMIT ISSUANCE OR
expenses which may accrue against said City in consequence of the
granting of this permit. Additionally,the applicant understands and will 180 DAYS FROM LAST CALLED INSPECTION.
comply with all non- oin rce regulations per the Cupertino Municipal
Code,Section .18.
Issued by:ABBY AYENDE
Dater 3/2/2016 a Q,Mr
Signature a e 3/2/2016
RE-ROOFS:
OWNER-BUI ER DECLARATION All roofs shall be inspected prior to any roofing material being installed.If a roof is
I hereby aftir that I am exempt from the Contractor's License Law for one of the installed without first obtaining an inspection,I agree to remove all new materials for
following tw'reinspection.
sons:
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 Signature of Applicant:
for sale(See.7044,Business&Professions Code) Date:3/2/2016
z 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:
1. I have and will maintain a Certificate of Consent to self-insure for Worker's HAZARDOUS MATERIALS DISCLOSURE
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
2. I have and will maintain Worker's Compensation Insurance,as provided for maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
by Section 3700 of the Labor Code,for the performance of the work for which Health&Safety Code,Section 25532(a)should I store or handle hazardous
this permit is issued. material. Additionally,should I use equipment or devices which emit hazardous
3. I certify that in the performance of the work for which this permit is issued,I air contaminants as defined by the Bay Area Air Quality Management District I
shall not employ any person in any manner so as to become subject to the will maintain compliance with the-Cuperthi Municipal Code,Chapter 9.12 and
the Health&Safety Cod cc' s/255725533,25533,and 25534.
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 author
lOwner or ized agent:
be deemed revoked. Date: /2/201
ONSTRU�TION LENDING AGENCY
APPLICANT CERTIFICATION I hereby affirm that there is qkonstruction lending agency for the performance
I certify that'I have read this application and state that the above information is of work's for which this per it is issued(Sec.3097,Civ C.)
correct.I agree to comply with all city and county ordinances and state laws Lender's Name
relating to building construction,and hereby authorize representatives of this city
to enter upon the above mentioned property for inspection purposes, (We)agree Lender's Address
to save indemnify and keep harmless the City of Cupertino against liabilities,
judgments,costs,and expenses which may accrue against said City in ARCHITECT'S DECLARATION
consequence of the granting of this permit. Additionally,the applicant I understand my plans shall be used as public records.
understands and will comply with all non-point source regulations per the
Cupertino Municipal Code,Section 9.18. Licensed
GENERAL PERMIT APPLICATION u mmm E P
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE CUPERTINO,CA 95014-3255
Ct,tPI RT(N63 (408)777-3228• FAX(408)777-3333• building(aDcugertino.ong MISIC
LUMBING ❑MECHANICAL ❑ELECTRICAL ❑MISCELLANEOUS
PROJECT ADDRESS I I n��J�^+�y 1 I c�() J C �C APN
OWNER NAME
J7,q• ( C y A /� ` PHONE �, l E-A4AIL
STREETADDRESS (Z7 I6 � (f�A41 / CITY, STATE:Z,IP" FAX
CONTACT NAME 6y "-•�l� PHONE q0q f_/ j'f[/ E-MAIL
STREETADDRES C� ( CI Y,STATE,ZIVPb FAX
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❑ owxER ❑ OwI\'ER•BUII.DER ❑ OWNER AGENT X-rCONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME r/! / ` LICENSE AIJMBER,�1.�, ( 2 LICENSE TYPE BUS.LIC 9 2
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COMPANY NAME E-MAIL_ J FAX
STREET ADDRES CITY STATE,ZIP PHONE �r�
r� ter, Gl�acu� C !/t�i
ARCHITECT/E-NGIN-EER NAME LICENSE NUMBER BUS.LIC#
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF ` FD.DUPLEX ❑ MULTI-FAMILY PROJECT IN WILDLAN'D ❑ YES PROJECT IN ❑YES IS THE BLDG AN El Es
BUII..DLN.G: ❑COMKERCIAL URBAN INTERFACE AREA 2-170 FLOOD ZONE �O EICHLER HOME? ONO
DESCRIPTION OF WORK
IS
TOTAL VALUATION: RECERBD BY: }
By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on the property owner's b half. I have read this
application and the information I have provided is correct. I 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 buil g c s ction. I authorize representatives of Cupertino to enter the above-identified property for inspection purposes.
tiz _ � z�
Signature of Applicant/Agent: Date:
S7MENTAL INFORMATION REQUIRED
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AlIEPAlliscApp_2011.doc revised 06121111