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B-2016-2152 CITY OF CUPERTINO BUILDING PERMIT BUILDINGADDRESS: CONTRACTOR: PERMIT NO:B-2016-2152 1110 MILKY WAY CUPERTINO,CA 95014-5009(362 20 004) B K CONSTRUCTION CASTRO VALLEY,CA 94546 OWNER'S NAME: TAMTORO KELWIN TRUSTEE&ET AL DATE ISSUED:06/16/2016 OWNER'S PHONE:408-203-3143 PHONE NO:(510)368-2878 LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: License Class B Lic.#962926 Contractor B K CONSTRUCTION Date 07/31/2017 X BLDG X ELECT _PLUMB T hereby affirm that I am licensed under the provisions of Chapter 9(commencing —MECH X_RESIDENTIAL— COMMERCIAL with Section 7000)of Division 3 of the Business&Professions Code and that my license is in full force and effect. JOB DESCRIPTION: I hereby affirm under penalty of perjury one of the following.two declarations: TEMPORARY POWER POLE(100 AMP) 1. 1 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 �`j�(f Section 3700 of the Labor Code,for the performance of the work for which this i} ermit is issued. Sq.Ft Floor Area: Valuation.$800.6,0 APPLICANT CERTIFICATION 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:i and state laws relating to building construction,and hereby authorize 362 20 004 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 WORK IS NOT STARTED may accrue against said City in consequence of the granting of this permit. WITFIIN 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 LAS CAI, ED SPECTION. Si nature Date 6!16/2016 Issued by:Alex Vallelunga Date:06/16/2016 OWNER-B IELDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for one of the RE-ROOFS: following two reasons: All roofs shall be inspected prior to any roofing material being installed.If aroof is 1. I,as owner of the property,or my employees with wages as 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 intended or offered for inspection. sale(Sec.7044,Business&Professions Code) 2. I,as owner of the property,am exclusively contracting with licensed Signature ofApplicant: contractors to construct the project(Sce.7044,Business&Professions Code). Date:6/16/2016 I 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. 1 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 s. 1 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 become 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 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,Sec' 25505,25533,and Labor Code,I must forthwith comply with such provisions or this permit shall be deemed revoked. — Owner or.authorizec agents APPLICANT CERTIFICATION Date:6/16/2016 I certify that I have readthis 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 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 6/16/2016 Professional GENERAL PERMIT APPLICATION COMMUNITY DEVELOPIdiENT DEPARTMENT• BUILDING DIVISION M E 10300 TORRE AVENUE- CUPERTINO, CA 95014-3255 (408)777-3228•FAX(408)777-3333•building(o7cuDertinO.OrgMl %;) u CUPIlE�TE�ita 6 f� _ �� ❑PLUNIMING ❑mECILkmc.-I ELECTRICAL ❑hfISCELLAhTEOUS PROJECT ADDRESS , APRT' o 01trhTcRNA E �, � I PI'01� �. ?7311 E,1/iAII STREETAD-DP.ESSCI�,STATE, '1 FAX CONTACT TAN_E `� PHOh l! E•A!iAIL STREETADDPeESS CITY,STATE,ZIP FAX ❑ ON'h�t ❑ OlvNM-BUILDER ❑ owNE t AGENT CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGi1NEER ❑ DEQ LLOPER ❑ TENANT CONTRACTOR NAh L&C I LICEN E NU7"BER TCENS£I-PE I BUS.LIC COIv4PANYNAb11E ` 9� E-AZAIL FAX STREETADDRESS • >,� fl ? CITY IATE,ZIP OTE .kRCETECT/ENNGINEER N'ME LICENSE NUMBER BUS.LIC COMPANY TAh4E �-D--MAIL �FAX STREET ADDRESSI CITY,STATE,ZIP i PHOTE USE OFFL'uDUP= ❑ 2,11ULTI•FAM LY I PROJECT L'\WILDLAh'D ❑ 1'ES PROJECT I N ❑YES IS TIT BLDG AN ❑ 1 s BUIDLI\10: jCOW51FRCLAL iiPB-ALNR,TERFACEAREA ❑ NO FLOOD LONE ❑No EICHLERHOME? ❑NO DESCRIPTION OF\VORI: tey,4,7 Pow0- 100 C1 TOTAL V-.LUATIO 1 /i RECFII'ED 13 i By my si_na ur o�;I certify to eaci"of e follo��ink: I am the property o«ner or authorized�2 nt to act on the property owners behalf. I have read this application and the information 1 have provided is coi.-ct. I have read the Description of Work and t eri}T it is accurate. I agree to comply with all applicable local ordinances and state laws relating to bui^ _ ction. I authorize re resentatives of Cupertino to enter the above-identified property for inspection purposes. Signature of".pplicant"a nt: Date: SUPPLE-MENTAL PvFOR>,I ATION REQUIRED OFFICE LSEOALI... . .... ,,✓;.' ❑ fl1'ER THE-CD UTTER ❑ EMPRESS h x v ❑ STAT�'D"RD c c � ?ZASOR .�ilEP/i?isc,5yp_?Ol Ldoc rerised 06./21/11