B-2016-1883CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS:
CONTRACTOR:
PERMIT NO: B-2016-1883
10200 JOHNSON AVE CUPERTINO, CA 95014-3812 (375 25 066)
DE ANZA BUILDERS
SAN JOSE, CA 95129
OWNER'S NAME: THOMAS REESA AND MATHEW
DATE ISSUED: 05/04/2016
OWNER'S PHONE: 4082618520
PHONE NO: (408) 865-0222
LICENSED CONTRACTOR'S DECLARATION
BUILDING PERMIT INFO:
License Class B Lic. #943227
Contractor DE ANZA BUILDERS Date 02/28/2018
X BLDG X ELECT _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:
INSTALL TEMP POWER (100 AMPS) - POLE
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
Sq. Ft Floor Area:
Valuation: $2000.00
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
APN Number:
Occupancy Type:
and state laws relating to building construction, and hereby authorize
37525 066
375
representatives of this city to enter upon the above mentioned property for
inspection purposes. agree to save indemnify and keep harmless the
City of Cupertino a inst Nabi ties, judgments, costs, and expenses which
PERMIT EXPIRES IF WORK IS NOT STARTED
may accrue again t said City ' consequence of the granting of this permit.
WITIIIN 180 DAYS OF PERMIT ISSUANCE OR
Additionally, thea plicant un erstands and will comply with all non -point
the upertino Municipal Code, Section 9.18.
source regulatiKIr"
180 DAYS FROM LAST CALLED INSPECTION.
Date 05/04/2016
1�nSignature
Issued by: PAUL O'SULLIVAN QQ
Date: 05/04/2016
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.
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: 05/04/2016
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 Cupetin unicipal Code, Chapter 9.12 and
the Health & Safety Code, ec 'ons 2 505, 25533, and 25534.
Owner or authorized agent:
Date: 05/04/2016
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 05/04/2016 Professic
GENERAL PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228 • FAX (408) 777-3333 • building(alcupertino.org
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USE OF ❑ SFD or DUPLEX ❑ 1 uTI-FAMILY PROJECT IN' IVILDLAND ❑ YES PROJECT IN ❑ YES
B1,U-DIN' G: ❑ COMMERCIAL URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑ NO
IS THE BLDG AN ❑ YES
EICHLER HOME? ❑ NO
DESCRIPTION OF WORK r I %�
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TOTAL VALUATION:
RECEIVED BI '
By my signature below, I certify to eachof the fo ]o in g- I am the property owner or authorized agent to act on thejoperty owner's behalf. 1 have read this
ide,. I have read the Description of'Work and verify it is accurate. I agree to comply with all applicable local
application and the information I have provd is co Tec
ordinances and state laws relating to bu ding cons ction. I authorize representatives of Cupertino to enter the above -identified rrproperty for inspection purposes.
Si --nature of Applicant/Agent: Date:
SULEMtNL INTFORMATION REQUIRED
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A7EPAlliscApp=2011.doc revised 06/21/11
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