B-2016-2293 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2016-2293
10235 VICKSBURG DR CUPERTINO,CA 95014-3358(369 07 011) GLEN GILBERT
• SAN JOSE,CA 95154
OWNER'S NAME: MEHTA MINOO AND PEREIRA JOSE DATE ISSUED:07/11/2016
OWNER'S PHONE:408499-4170 PHONE NO:(408)377-9990
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class SANITATION SYSTEM Lic.#677475 X BLDG —ELECT X PLUMB
Contractor GLEN GILBERT 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:
INSTALL N PROPERTY LINE CLEANOUT
I hereby affirm under penalty of perjury one of the following two declarations:
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
�`erformance of the work for which this permit is issued.
z. v/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. Sq.Ft Floor Area: Valuation:$2500.00
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 69 Number: Occupancy Type:
3
and state laws relating to building construction,and hereby authorize 369 07 011
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. WITHIN 180 DAYS OF PERMIT ISSUANCE OR
Additionally,the applicant understands and will comply with all non-point
source regul s per the Cupertino Municipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
Signatu Date 07/11/2016 Issued b
Date:07/11/2016
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of the RE-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 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(Scc.7044,Business&Professions Code)
z. I,as owner of the property,am exclusively contracting with licensed Signature of Applicant:
contractors to construct the project(Scc.7044,Business&Professions Code). Date:07/11/2016
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
2. 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. I will
t is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
permi
Health&Safety Code,Section 25532(a)should I store or handle hazardous
3. I certify that in the performance of the work for which this permit is issued I material. Additionally,should I use equipment or devices which emit hazardous
shall not employ any person in any manner so as to become subject to the
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, on 505,25 ,a 25534.
Labor Code,I must forthwith comply with such provisions or this permit shall
be deemed revoked. Owner or authorized agent:
APPLICANT CERTIFICATION Date:07/11/2016
I certify that I have read this application and state that the above information is Cl1NSTRUCTION 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
I understand my plans shall be used as public records.
Code,Section 9.18.
Licensed
Signature Date 07/11/2016 professional
GERlEl2/aL PERMIT APPLICATION MEP
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE.CUPERTINO,CA 95014-3255 MISCCUPERTt[VO
(408)777-3228• FAX(408)777-3333•building(d)cupertino.org
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PLUMBING MECHANICAL ❑ELECTRICAL ❑MISCELLANEOUS
PROJECT ADDRESS i
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CONTACT NAME 1 HONBogI 7 E-MAIL
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COMPANY NAME E-MAIL FAX
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USE OF ❑ SFD or Duplex El Multi-Family PROJECT IN WILDLAND PROJECT IN
STRUCTURE: ElCommercial URBAN INTERFACE AREA ❑ Yes NO FLOOD ZONE ❑ Yes 0
DESCRIPTIO !20RK;
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TOTAL VALUATION: 00 VED
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 vided 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 t u' ing construction thorize re entatives of Cupertino to enter the above-identJified pro,erty for in purposes.
Signature of Applicant/Agent: Date:
SUPPLEMENTAL INFORMATION REQUIRED OFFICE usE ONLY a
VER-THE COUNTER
J� w STANDARD
w
MAJOR
MEPMiscApp_2011.doe revised 03116111