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B-2016-1647 CITY OF CUPERTINO BUILDING PERMIT BUILDINGADDRESS: CONTRACTOR: PERMIT NO:B-2016-1647 10241 SANTA CLARAAVE CUPERTINO,CA 95014-1216(326 22 010) JONATHAN WEI CHIN SU CUPERTINO,CA 95014 OWNER'S NAME: ISTAKAHMAIED DATE ISSUED:03/28/2016 OWNER'S PHONE:4082301163 PHONE NO:(408)255-8999 LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: License Class B Lic.#01633 1633 Contractor JONATHAN WEI CHIH SU Date 12/31/2017 X BLDG X ELECT _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: INSTALL TEMPORARY POWER(100 AMPS) 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. Sq.Ft Floor Area: Valuation:$500.00 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 26 Number: Occupancy Type: 3 and state laws relating to building construction,and hereby authorize 326 22 010 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 PERMIT EXPIRES IF WORK IS NOT STARTED may accrue against said City in consequence of the granting of this permit. WITHIN 180 DAYS OF PERMIT ISSUANCE OR Additionally,the applicant understands and will comply with all non-point source regulations per the Gupert' %lunicipal de,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION. Signature Date 3/28/2016 Issued by:PAUL O'SULLIVAN Date:3/28/2016 OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for one of the RE-ROOFS: following two reasons: All roofs shall be inspected prior to any roofing material being installed.If a roof is 1. I,as owner of the property,or my employees with wages as their sole installed without first obtaining an inspection,I agree to remove all new materials for compensation,will do the work,and the structure is not intended or offered for inspection. sale(Sec.7044,Business&Professions Code) 2. I,as owner of the property,am exclusively contracting with licensed Signature of Applicant: contractors to construct the project(Sec.7044,Business&Professions Code). Date:3/28/2016 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 performance of the work for which this permit is issued. HAZARDOUS MATERIALS DISCLOSURE 2. I have and will maintain Worker's Compensation Insurance,as provided for by I have read the hazardous materials requirements under Chapter 6.95 of the Section 3700 of the Labor Code,for the performance of the work for which this California Health&Safety Code,Sections 25505,25533,and 25534. I will permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&Safety Code,Section 25532(a)should I store or handle hazardous s. I 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 Worker's Compensation laws of California. If,after making this certificate of will maintain compliance with the Cupertino Municipalkode,Chapter 9.12 and exemption,I become subject to the Worker's Compensation provisions of the the Health&Safety Code, a do 25 , 5533,and 25534. Labor Code,I must forthwith comply with such provisions or this permit shall be deemed revoked. Owner or authorized agent: APPLICANT CERTIFICATION Date:3/28/2016 I certify that I have read this application and state that the above information is CONSTRUCTION LENDING AGENCY correct.I agree to comply with all city and county ordinances and state laws I hereby affirm that there is a construction lending agency for the performance relating to building construction,and hereby authorize representatives of this city of work's for which this permit is issued(Sec.3097,Civ C.) to enter upon the above mentioned property for inspection purposes. (We)agree Lender's Name to save indemnify and keep harmless the City of Cupertino against liabilities, judgments,costs,and expenses which may accrue against said City in Lender's Address consequence of the granting of this permit. Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal ARCHITECT'S DECLARATION Code,Section 9.18. 1 understand my plans shall be used as public records. Licensed Signature Date 3/28/2016 Professional GENERAL PERMIT APPLICATION MEP COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION 10300 TORRE AVENUE• CUPERTINO, CA 95014-3255 MISC (408)777-3228• FAX (408) 777-3333•building(alcupertino.org CUPERT:INO ❑PLUMBING ❑MECHANICAL [:]ELECTRICAL ❑MISCELLANEOUS PROJECT ADDRESS /O j 41 Eaw�Q /�� V� APN# 3 OWNER NAME / l/I PHONE ,5 � ,,�O„f// E-VAIL Ake STREET ADDRESS CITY, �1TE,ZIP /,,�j �� FAX /o �o fC C��t ,c �i no CONTACT NAME PHO 8) E-MAIL u A\ j�gO 100' LG STREETADDRESS /0 0h �r ,!n ` CITY,STATE,ZIP 7 � AX ❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT CONTRACTOR 1-1CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME LICENSE NU BER �j LICENSE TYPE j] BUS.LIC# 3 COMPANY NAME �+ E-MAIL FAX 16 02M 2feea �QO STREET ADDRESSrjj CITY,STATE,ZIP T PHONE ARCHITECT/ENGINEER NAME },1�� LICENSE NUMBER BUS.LIC# 1E (f COMPANY NAME n `Ac�(/^c(p -TE-S E-MAIL FAX CITY,STATE,ZIP � �1 PHONE STREET ADDRESS /�Z2 C oor� � T v oy qa' � i,� v 62 04� USE OF SFD or DUPLEX ❑ MULTI-FAMB,Y PROJECT IN WILDLAND YES PROJECT IN ❑YES IS THE BLDG AN ❑ YES BUILDING: ❑COMMERCIAL URBAN INTERFACE AREA NO FLOOD ZONE NO EICHLER HOME? NO DESCRIPTION OF WORK AM®!/v TOT=VALUATION: `to RECEIVED BY By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on the p k perry owner's behalf. 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 building constru I au o ze representatives of Cupertino to enter the abo��eentifiedproperty for inspection purposes. Signature of Applicant/Agent: Date: j-CC2 SUPPLEMENTAL INFORMATION REQUIRED OI+FlCg.USE ONLY,,,' OYERSs tH -COTJNTER V ❑ STANDARD C ❑ Le1RGR � ❑•MAJOR MEPMiscApp 2011.doc revised 06/21/11