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B-2016-2221 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2016-2221 10600 CULBERTSON DR CUPERTINO,CA 95014-3555(375 34 033) CHANG CHUAN-MIN SAN JOSE,CA 95129 OWNER'S NAME: LIN ROCKY AND ALICE DATE ISSUED:06/28/2016 OWNER'S PHONE:949-334-7259 PHONE NO:(408)206-9936 LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: License Class GENERAL BUILDING CONTRACTOR Lic.#505260 Contractor CHANG CHUAN-MIN Date 07/31/2017 X BLDG X ELECT _PLUMB I hereby affirm that I am licensed under the provisions of Chapter 9(commencing MECH X RESIDENTIAL_COMMERC 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:oneof the following.two declarations: NEW TEMPORARY POWER POLE(100 AMPS)-ABOVE 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 Labor Code,for the 1p ormance of the work for which this permit is issued. 2. ave and will maintain Worker's Compensation Insurance,as provided for by ection 3700 of the Labor Code,for the performance of the work for which this i permit is issued. Sq.Ft Floor Area: Valuation:$200.00 1 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:. and state laws relating to building construction,and hereby authorize 375 34 033 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 OT 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 CALLEID INSPECTION. �j /S' ignature —r �, i Dae 6/2812016 Issued by:Abby Ayende (1 Date:06/28/2016 OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Co ntr tor's Lic rise Law for one of the RE-ROOFS: following two reasons: All roofs shall be inspected prior to any roofing material being installed.If a roof is 1. I,as owner of the property,or my employees with w ges as their sole installed without first obtaining an inspection,I agree to r move all new materials for compensation,will do the work,and the structure is aot intended or offered for inspection. sale(See.7044,Business&Professions Code) 2. 1,as owner ofthe property,am exclusively contractfi ig with licensed Signature of Applicant: contractors to construct the project(Sec.7044,Busin ss&Professions Code). Date;6/28/2016 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 elf-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 ui ider 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 C de,Chapter 9.12 and the 3. 1 certify that in the performance of the work for whi h 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 toecome subject to the material. Additionally,should I use equipment or de ces which emit hazardous air contaminants as defined by the Bay Area Air Qua ty Management District I Worker's Compensation laws of California. If,after making this certificate of will maintain compliance with the Cupertino Municip il Code,Chapter 9.12 and exemption,I become subject to the Worker's Compensation provisions of thethe Health&Safety Code,S tions 25505,2 533,and 534. Labor Code,I must forthwith comply with such provisions or this permit shall be deemed revoked. t ner or authorized agent: - APPLICANT CERTIFICATION -Date: 26i 8/2016 certify that I have read this application and state that the above information is CONSTRUCTION LENDING AN Y 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 erformance 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 DE RATIN Code,Section 9.18. 1 understand my plans shall be used as public recorc s. Signature Date /6.28/2016 Licensed Si g Professional GENERAL PERMIT APPLICATION EP COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 CUPERTINO (408)777-3228•FAX(408)777-3333•building(ftupertino.ong Isc-2-wo- 222 ❑PLUMBING ❑MECHANICAL ❑ELECTRICAL ❑MISCELLANEOUS PROJECT ADDRESS � q ' S r0bpb CuLW—{ 5JVM D�... _ APN# qa— a)q,o2 OWNERNAME �� C IU l �i J t l -70 E MAIL kry ,�y y l STREET ADDRESSt. b CITY,STATE,ZIjl PQ �� e g�°g� 16 f FAX( CONTACT NAME`` '� �^ �o PHONE�+�}a ( `"E-MAIL l� n@ STREET ADDRESS 7 CITY,STATE,ZIP FAX ,OWNER ❑ OwNER-BUH.DER ❑ owNER AGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVEL.PER ❑ TENANT CONTRACTOR NAME LICENSE NUMBER, 6, LICENSETYPE BUS.LIC# s s �•�p y� COMPANY NAME E-MAIL FAX �-�( � A.4~--lel STREET ADDRESS j� t�(I,B, n CIT SATE, IP c PHO ca qs ARCHITECVENGINEER NAME 4 A LICENSE NUMBER c" BUS.LIC# COMPANY NAME TGA r)f� R ±CITY ISTATI FAX STREET ADDRES( �et E? , 5, A oa s� Wb USE OF K-SFD or Duplex E] Multi-Family PROJECT IN WILDLAND (� PROJECT`IN 7 STRUCTURE: ❑ Commercial URBAN INTERFACE AREA ❑ Yes NO FLOOD ZONE ❑ Yes ❑i 0 CRIPTION OF ORK TOTAL VALUATION: 11W REC,EIVED"BY ,, ,° By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on the properly owner's behalf. I have rad this application and the information I have p•vided is correct. I have read the Description of Work and verify it is accurate. I agree to comply with all app 'cable local ordinances and state laws relating t ding const ruction. I authorize r�tat 'aRupertino to enter the abov-id t��;pgy for inspectio purposes. Signature ofApplicant/Agent: Gf 1 Date: SUPPLEMENTAL INFORMATION P IRED OFFICE 7SI ,,;NLY W I❑ �Y EIt-THE OUNT'ER . 0 EXPRESS , -. . STANDARD' U , >ti a ❑ LARGE' � r IIRAJOR' MEPMiscApp_2011.doc r vised 03/16/11