B-2016-1422CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: P p
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CONTRACTOR:
CONTRACTOR: Y, '�,, y PERMIT NO: p -y
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OWNER'S NAME: �Ck Wei 4 h, iR
DATE ISSUED: ell
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OWNER'S PHONE:
PHONE NO:
❑ LICENSED NSED CONTRACTOR'S DECLARATION`
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BUILDING PERMIT INFO: BLDG ` " r7.1 ELECT .PLUMB
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License Class Lic. #F.
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Contractor 1�4 1 r 1 DW Date
MECH RESIDENTIAL COMMERCIAL
I hereby affirm that I am licensed under the provisions of Chapter 9
JOB DESCRIPTION:
(commencing with Section 7000) of Division 3 of the Business &Professions
Code and that m license is in full force and effect.
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I hereby affirm under penalty of perjury one o the following two declarations:
I have and will maintain a certificate of consent to self-insure for Worker's
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Compensation, as provided for by Section 3700 of the Labor Code, for the
performance of the work for which this permit is issued.
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I have and will maintain Worker's Compensation Insurance, as provided for by
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Section 3700 of the Labor Code, for the performance of the work for which this
Sq. Ft Floor Area:
Valuation:
permit is issued.
APPLICANT CERTIFICATION
APN Number:
Occupancy Type:
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,
PERMIT EXPIRES IF WORK IS NOT STARTED
costs, and expenses which may accrue against said City in consequence of the
granting of this permit. Additionally, the applicant understands and will comply
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
with all non-point source regulations per the Cupertino Municipal Code, Section
180 DAYS FROM LAST CALLED INSPECTION.
9.18..,
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Signature ,� Date v D
Issued by: "n C AWd. CDate:
❑ OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of
RE-ROOFS:
the following two reasons:
I, as owner of the property, or my employees with wages as their sole compensation,
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
will do the work, and the structure is not intended or offered for sale (Sec.7044,
inspection.
Business & Professions Code)
I, as owner of the property, am exclusively contracting with licensed contractors to
Signature of Applicant: Date:
construct the project (Sec.7044, Business & Professions Code).
I hereby affirm under penalty of perjury one of the following three
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
declarations:
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
HAZARDOUS MATERIALS DISCLOSURE
performance of the work for which this permit is issued.
I have read the hazardous materials requirements under Chapter 6.95 of the
I have and will maintain Worker's Compensation Insurance, as provided for by
California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain
Section 3700 of the Labor Code, for the performance of the work for which this
compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health &
permit is issued.
Safety Code, Section 25532(a) should I store or handle hazardous material.
I certify that in the performance of the work for which-this permit is issued, I shall
Additionally, should I use equipment or devices which emit hazardous air
contaminants as defined by the Bay Area Air Quality Management District I will
not employ any person in any manner so as to become subject to the Worker's
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
Compensation laws of California. If, after making this certificate of exemption, I
Health & Safety Code, Sections 25505, 25533, and 25534.
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.
OwneX.thori a t: Z� /
O' Date: f (%
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is
C —TION LENDING AGENCY
correct. I agree to comply with all city and county ordinances and state laws relating
I hereby affirm that there is a construction lending agency for'the performance of work's
to building construction; and hereby authorize representatives of this city to enter
for which this permit is issued (Sec. 3097, Civ C.)
upon the above mentioned property for inspection purposes. (We) agree to save
Lender's Name
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
costs, and expenses which may accrue against said City in consequence of the
Lender's Address
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.
ARCHITECT'S DECLARATION
Signature Date
I understand my plans shall be used as public records.
Licensed Professional
c.ONSTRUCTION PERMIT APPLICATION Ifo- UP9
COMMUNI TY DEVELOPMENT DEPARTMENT - BUILDING DIVISION
10300TORRE AVENUE - CUPER T 1NO, CA 55014-3255
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CUP>~RTIh10- (408) 777.3228 - FAX (408) 777-3333 • buildlnOfc-PCUDefrtino.Drq
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=STAG USE FROPOSED USE CONSTRTY713 I K STDRO S
ordinances znd state 12-ws relating #o building co< t tion. I`t;+thorize re +�tives �iCupertino
to anter the ebovc-identi
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SUPPI,ERrr, NTAL WFORMATION REQUIRE
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_Copy of Plannin, Approval Letter or Meeting with Planning prion to •'
submittal of BuildingPermit application,
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13y my signature oelow, t cerlry to earn of tno totlowmg: t am the propany ot,,aer or authorised agent to act on the proper+,
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ordinances znd state 12-ws relating #o building co< t tion. I`t;+thorize re +�tives �iCupertino
to anter the ebovc-identi
SignatureofApplicanNAgent:..
_. Date:....
SUPPI,ERrr, NTAL WFORMATION REQUIRE
New SFD or Multifamil d-,vellintrs: AD1 for demolition ennit for
existing building (s)• Demolition perinit is required prior to issues il
ce of budin;
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for building,
permit new
Commercial Pldgs: Provide a completed Hazardous Materials Disclosure
70_rfn if any Haaardons Materials are being used as part of this project.
_Copy of Plannin, Approval Letter or Meeting with Planning prion to •'
submittal of BuildingPermit application,
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ow'ner's behalf I have read this
ee•to�omply ��vitlsrll' applicable 1'dc`aC -'
ped p,roO ,,y for%'nspection purposes,
Blootlpp_?011.doc revised 06/21/1
CitN Of Cupertino
10 300 Torre Avenue
Cupertino, CA 95014-3'55
Telephone: 408-777-3228
Fax: 408-77-7-3133-3,
CONTRACTOR SUBCONTRACTOR LIST
'JOB, ADDRESS: Z0E-6'1 PERNMIT #:
OWNER'S NAME: ej,14:271
GENERAL CONITRACTOR-,
j ADDRESS:Z-0,6��, o ;V qL-!� ESSI-I'CFNSE #
V211-114 1-'Ilwr�t CODE:
"Our municipal code requires all businesses Niorking in the city to have a City of Cupertido' business license.
NO BUILDING FINAL OR FIN..*%L OCCURANCY INSPECTION(S) NVILL BE SCHEDULED UNTIL THE
GENERAL CONTk�CTOR AND ALL SUBCONTRACTORS HXVE OBTkINED A CITY OF CUPERTINO
BUSINESS LICENSE.
I am not using any subcontractors:
Signature
Please check applicable subcontractors and complete the following information:
Date
V SUBCONTRACTOR BUSINESS NA-NME 1 BUSINESS LICENSE #
10
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Linoleum / Wood
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Landscaping -;L;,
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