B-2016-2128CITY OF
UPERTINO BUILDING PERMIT
BUILDING ADDRESS:
CONTRACTOR:
PERMIT NO: B-2016-2128
10330 MENHART LN CUPERTINO, CA 95014-3631 (375 16 017)
GRAND - NEST
CONSTRUCTION
SARATOGA, CA 95070
OWNER'S NAME: MENHART PRIME LLC
DATE ISSUED: 06/14/2016
OWNER'S PHONE: 510-789-6050
PHONE NO: (408) 891-8059
LICENSED CONTRACTOR'S DECLARATION
BUILDING PERMIT INFO:
License Class GENERAL BUILDING CONTRACTOR Lic. #9B5412
X BLDG X ELECT PLUMB
Contractor GRAND - NEST CONSTRUCTION Date 09/30/2017
_
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 AMP); POLE/ABOVE
I hereby affirm under penalty of perjury one of the following twol declarations:
GROUND
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 La or Code, for the
R��L-$erformance of the work for which this permit is issued.
U, z. 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: $500.00
permit is issued.
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above
is I to
"N Number:
Occupancy Type:
information correct. agree comply with all city and count ordinances
375 16 017
and state laws relating to building construction, and hereby autorize
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 expehses which
PERMIT EXPIRES IF WORK 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.
Signature /`J�� ��� _ Date16/ 4/2016
Issued by: Abby Avende2!_p
9jewQ
Date: 06/14/2016
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of the
RF 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 Is their sole
installed without first obtaining an inspection, I agree to remove all new materials for
compensation, will do the work, and the structure is not in ended 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: 6/14/2016
1 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
z. 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. 1 will
permit is issued,
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
a. 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
shall not employ any person in any manner so as to becom subject to the
material. Additionally, should I 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
I become to the Worker's Compensation of the
will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and
Safety Code, Sections 25505, 25533, 25534.
exemption, subject provisions
Labor Code, I must forthwith comply with such provisions or this permit shall
the Health & and
be deemed revoked.
Owner or authorized agent:
APPLICANT CERTIFICATION
Date: 6/14/2016
I 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 to
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.
Licensed
Signature Date 6/14/2016
Professional
CUPERTINO
GENERAL PERMIT APPLICATION MEP
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228 • FAX (408 777-3333 • build! ng(a)cupertino.org MISC
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USE OF ❑ SFD or Duplex ❑ Multi -Family
STRUCTURE: ❑ Commercial
ROJECT IN WILDLAND
RBAN INTERFACE AREA ❑ Yes ❑ NO
PROJECT IN
FLOOD ZONE ❑ Yes ErNO
DESCRIPTION OF WORK Iu V A
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TOTAL VALUATION:
RECEIVED BY;'
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By my signature below, I certify to each of the following: I am the (property owner or authorized agent to act on the property owner's behalf. I have read this
application and the information I have provided is correct. I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating to building construction. I authorize representatives of Cupertino to enter the above -identified rope for inspection purposes.
Signature of Applicant/Agent: Date:
SUPPLEMENTAL INFORMATION REQUIRED
orFtcE USE ONLY
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