B-2016-1651CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS:
23500 CRISTO REY DR UNIT 406F CUPERTINO, CA 95014-6531 (342 53 173)
CONTRACTOR:
BAY AREA
PERMIT NO: B-2016-1651
ENTERPRISE
SAN JOSE, CA 95148
OWNER'S NAME: LARSON CARL V TRUSTEE & ETAL
DATE ISSUED: 03/30/2016
OWNER'S PHONE: 650-537-1523
PHONE NO: (408) 238-5043
LICENSED CONTRACTOR'S DECLARATION
BUILDING PERMIT INFO:
License Class GENERAL BUILDING CONTRACTOR Lic. #817817
Contractor BAY AREA ENTERPRISE Date 03/31/2017
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:
REPLACE SHOWER PAN, WALLS (TILE) & SHOWER VALVE IN
1. I have and will maintain a certificate of consent to self-insure for Worker's
HALL BATH
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.
t
Sq. Ft Floor Area:
Valuation: $4500.00
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above
APN Number:
Occupancy Type:
information is correct. I agree to comply with all city and county ordinances
and state laws relating to building construction, and hereby authorize
34253 173
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 thegranting of this _p
Additionally, the applicant understands and will comply with all non-point
nt
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
source regulations per the Ca{ertino Municipal Code, Section 9.18.
180 DAYS FROM LAST YIWECTION.
Signature-1_51' f P Date 03/30/2016
Issued by: MELIW
Date: 03/30/2016
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
t. I, as owner of the property, or my employees with wages as their sole
installed without fust obtaining an inspection, I agree to remove
11 new materials for
compensation, will do the work, and the structure is not intended or offered for
inspection.
IIII
sale (Sec,7044, Business & Professions Code)
2. I, as owner of the property, am exclusively contracting with licensed
Signature ofApplicant
contractors to construct the project (Sec.7044, Business & Professions Code).
Date: 03/30/2016
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
ALL ROOF COVERINGS TO BE CLASS "A" OR
BETTER
J
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 C�apter 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, acrd 25534. I will
permit is issued.
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
3. I certify that in the performance of the work for which this permit is issued, I
Health & Safety Code, Section 25532(x) should I store or hlandle hazardous
Additionally, I
shall not employ any person in any manner so as to become subject to the
material. should use equipment or devices which emit hazardous
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 Muni ipaL"C-model, Chapter 9.12 and
exemption, I become subject to the Worker's Compensation provisions of the
the Health & Safety Code, G�:4�; 25533, 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: 03/30/2016
I certify that I have read this application and state that the above information is
CONSTRUCTION LENDING A EN Y
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.
Signature Date 03/30/2016
Licensed
Professional
COMMUNITY DEVELOPMENT DEPARTMENT - BUILDING DIVISION
10300 TORRE AVENUE - CUPERTINO, CA 95014-3255
CUPIERTWO 1 (411) 117-3228 - FAX (408) 777-3333 ® building0cupertino.orci r3- tou - r6 5 t
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By my signature below, I certify to each of the folio g: I am the property owner or u
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application and the information I have prov is c, et_ I ha the Description o brk and verify it is accurate. I agree to comply with all a cable local
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ordinances and state laws relating to building ction Drize representatives of Cupertino to enter the above -id
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Signature ofApplicant/Agerit
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SUPPLEMENT 4<L INFORMATION REQUIRED
LAN[ HI?CI TYw
-ROUTING SLIP -
New SFD or Multifamily dwellings: Apply for demolition permit for
existing building(s). Demolition permit is required prior to issuance of building
permit for new building.
0,
PLAN14ING
Commercial Bldgs: Provide a completed Hazardous Materials Disclosure
0 sT -AND
form if any Hazardous Materials are being used as part of this projecL
0 LARGE
-IFH�W
Copy ofPlanning Approval Letter or Meeting with Planning prior to
D.
submittal of Building Permit application.
B1dg,4pp__,2011.doc revised 06121111