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B-2016-1877CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: CONTRACTOR: PERMIT NO: B-2016-1877 19025 PENDERGAST AVE CUPERTINO, CA 95014-3516 (375 37 043) D W K CONSTRUCTION CUPERTINO, CA 95014 OWNER'S NAME: XIE, YUCHEN SEPARATE PROPERTY TR 11/16/12 DATE ISSUED: 05/03/2016 OWNER'S PHONE: 408-768-7530 PHONE NO: (408) 429-8503 LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: License Class B Lic. #820027 Contractor D W K CONSTRUCTION Date 05/31/2017 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: NEW TEMPORARY POWER POLE (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. 00I 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: $300.00 4/- permit is issued. 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 375 37 043 375 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 PERMIT EXPIRES IF WORD 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 Cupertino Municipal Code, Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION. $i nature G Date 5/3/2016 Issued by: Abby A e� nde n� Date: 05/03/2016 IA OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for one of the RE -ROOFS: All roofs shall be inspected prior to any roofing material being installed. If a roof is following two reasons: 1. I, as owner of the property, or my employees with wages as their sole installed without fust 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: 5/3/2016 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 3. I certify that in the performance of the work for which this permit is issued, I Health & Safety Code, Section 25532(a) should I store or handle hazardous 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 Municipal Code, Chapter 9.12 and exemption, I become subject to the Worker's Compensation provisions of the the Health & Safety Code, Sections 25505, 25533, and 25534. Labor Code, I must forthwith comply with such provisions or this permit shall be deemed revoked. Otho er or authorized agent: 60 APPLICANT CERTIFICATION 41 ? ate: 513/2016 1 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 Flame 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 I understand my plans shall be used as public records. Code, Section 9.18. Licensed Signature Date 5/3/2016 Professional tCUPERTINO GENERAL PERMIT APPLICATION MEP COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 • build i no5cu perti n o.g.M w miscr ❑ PLUMBING ❑ MECHANICAL 2QELECTRICAL ❑ MISCELLANEOUS PROJECT ADDRESSAPN # OVINIERNAMEj/� C�� 1 j r le PHONE O (,� j(a jS� E MAIL STREET ADDRESS, -. Fel . �, �_ �e CITYSTATE, ZIP ) J © J eA CONTACT NAME u 1 . PHONE -08) 7, � E-MAIL, STREET ADDRESS / �a (} 4,14 -RIA G J �Q` CITY, STATE, ZIP ��,� r 1_C %1 7 FAX ❑ OWNER ❑ OWNER -BUILDER ❑ OWNER AGENT CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME S--c� � �{/�/%y LICENSE NUMBER n n „ ��7 LICENSE TYPE t3 BUS. LIC #2, COMPANYNAME �E MAI,�'j G f els SAX0/v�ifYh eo STREET ADDRESS CITY, STATE, ZIP PHONEi ARCHITECT/ENGINEER NAME LICENSE NUMBER V BUS. LIC # COMPANY NAME E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE USE OF ❑ SFD or DUPLEX ❑ MULTI -FAMILY PROJECT IN WILDLAND ❑ YES PROJECT IN ❑ YES IS THE BLDG AN ❑ YES BUILDING: ❑ COMMERCIAL I URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑ NO EICHLER HOME? ❑ NO DESCRIPTION OF WORK MEPAIiscApp_2011.doc revised 06/21111 'no.ce,