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B-2016-2007CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: CONTRACTOR: PERMIT NO: B-2016-2007 11130 CHADWICIC PL CUPERTINO, CA 95014-4705 (3 56 17 08 1) MAIN STREAM ELECTRIC FOLSOM, CA 95630 OWNER'S NAME: MINASSIAN GEORGIC AND ALIECE DATE ISSUED: 05/24/2016 OWNER'S PHONE: 408-772-3923 PHONE NO: (916) 439-5253 LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: License Class CC10 Lic. #912100 X BLDG X ELECT Contractor MAIN STREAM ELECTRIC Date 03/31/2018 _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: REPLACE MAIN PANEL (200 AMP); SAME LOCATION 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. 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. 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. �l�4��� Signature Date OWNER -13 iLDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: r. 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) z. 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: i. 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. 1 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. Sq. Ft Floor Area: I Valuation: $2200.00 APN Number: Occupancy Type: 356 17 081 PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTION. Issued by: Phucing Devrie Date: 05/24/2016 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 Date: ALL ROOF COVERINGS TO BE CLASS "A" OR 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 Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Sections 25505, 25533, and 25534. Owner or authori ed agent: Date: O CNSTRUCTION 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 understand my plans shall be used as public records. Licensed Signature Date Professic GENERAL PERMIT APPLICATION a. COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION E. 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 • buildingacuoertino.org CUPERTIN0 ❑ ELUMBINC, ❑MIECHAISICAL ELECTRICAL ❑MISCELLAINTEOUS 4t PROJECT ADDRESS I APN n - AG ZF e� � 5 l -I o-3 O'WNTR NAI,1E f [ P E -M AM - STREET ADDRESS G CI STATE, ZIP�� FAX CONTACT NAME;^ PHO��-6!D6— 9 0 STREET ADDRE CIAT ,ZIP FAX El Owi\:ER ❑ Owh-,:R-BUJJ.DER fl ONR.'ER AGENT ❑ CONMCTOR"- - 01, RACTOR AGENT ❑ ARCHITECT ❑ nzoL,\ ER ❑ DEVELOPER ❑ TENANT CONTRA O NAi 1 / I LIC TS 4B LICENSE TYPE I BUS. LIC 4 Lqk�eaGYM T r. COMP.A141Y NAME E-M4P�IL / / FAX S SS �i / L-,, c / � �h CI T. TE, ZIP � ry_ / v "� 6 P ONE r ARCMTECT/F_JGLNEER NAM4E LICENSE NUMBER BUS. LIC COMPANY NAME E-NLML FAX STREET ADDRESS CITY, STATE, ZIP PHONE USE OF I `SFD ❑ mut.Ti-FAMILY PROJECT IN WILDLAND ❑ - ES PROJECT IN ❑ Y'ES IS THE BLDG AN ❑ Y'ES BU=NG:El COMMERCIAL URBAN INTERFACE AREA ❑ NO FLOOD ZONE O El N EICHLER HOM'4E? u I DESCRIPTION OF WORK TOTAL\%ALUATION: Z � I RECEIVED By my si=nature below, I certify to each of the following: I am the property owner or authorized agent to act on r poee Hrs behalf. I have read this application and the information 1 have provided is correct. I have re d the Description of NVork and verify it is accura _ teo comply with all applicable local ordinances and state laws relating to " o u ening to enter the above -id tifred pro rty for inspection purposes. Signature of Applicant%.-ent• Date: UPP : MENTAL INF0R2,dATIO1\T REQUIRED:OFFICE _:f r LSE:OrLl rt < ysx J % ,F J STi>\TJ4RD r R. kR © 7!1.AJ0 R'--; ,:rx.:.'.4 hlEP?,fiscApp_?01 ].doc revised 06121/11