D-2016-0390CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS:
CONTRACTOR:
PERMIT NO: D-2016-0390
18780 TILSON AVE CUPERTINO, CA 95014-3858 (375 17 036)
PAB CONSTRUCTION
i
INC
CUPERTINO, CA 95014
OWNER'S NAME:, Waak (Af3,0
DATE ISSUED: 07/07/2016
OWNER'S PHONE: 408-504-1061
PHONE NO: (408) 499-6595
LICENSED CONTRACTOR'S' DECLARATION
BUILDING PERMIT INFO:
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License Class GENERAL BUILDING CONTRACTOR Lic. #980537
BLDGELECT PLUMB
Contractor PAB CONSTRUCTION INC Date 01/31/2017
— — —
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:
HOUSE DEMO (1100 S.F.)
I hereby affirm under penalty of perjury one of the following two declarations:
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.
2. 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: $8000.00
permit is issued.
APPLICANT CERTIFICATION
certify that I have read this application and state that the above
APN Number:
Occupancy Type:
information is correct..I agree to comply with all city and county ordinances
and state laws relating to building construction, and hereby authorize
375 17 036
375
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 ap [icon understands and will comply with all non -point
source regulations `er th Cu ertino Municipal Code, Section 9.18.
180 DAYS FROM LAST CALLED INSPECTION.
Signature Date 7/7/2016
Issued by: Abby Ayende
Date: 07/07/2016
O E - dR DECLARATION
I hereby affirm tat I am exempt from the Contractor's License Law for one of the
BE -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 (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: 7/20 16
I hereby affirm under penalty of perjury one of the following three declarations:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
i. 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
permit is issued.
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
3. 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
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 Cunertino Municipal Code, Chapter 9.12 and
exemption, I become subject to the Worker's Compensation provisions of the
the Health & Safety Code, ect'i ns 25505, 25533, and 25534.
Labor Code, I must forthwith comply with such provisions or this permit shall
be deemed revoked.
Owner or authorized agent:
APPLICANT CERTIFICATION
Date: 201
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
TRUI�i LENDING AGENCY
C
I hereby affirm that there is a c s$ruction lending agency for the performance
relating to building construction, and hereby authorize representatives of this city
of work's for which this permit is sued (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 /2016
Professional
DEMOLITION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228 • FAX.(408) 777-3333 • buildina(a)cupertino.ora
PROJECT ADDRESS v e , APN# p-oquo
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OWNERNAME \ �/� 1 . _ PHONE �rq Gly G� 1,0
Q b E QabCe.n S �►e ®` w��
STREET ADDRESS �Ve7 p �1 , eH A s / CITY, STATE, ZIP n r �in a FAX
CONTACT NAME � � ru C� \ YC 1Y) PHONE a ' Q Q li ,q i- d�J E-MAILp 0.10 C+ n g W1 `
STREET ADDRESS 1 6 1 \ I CITY, STATE,�IP pP6, 1 FAX
❑ OWNER ❑ OWNER -BUILDER ❑ OWNERAGENT OB C` ONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRAC OR NAME` LICENSE piIJMB_F�R LICENS E BUS. LIC #
COMPANY NAME�iMAH i Es I FAX (J1.G7
PAG QanSkluc1lr, a�CerSin'L
STREET ADDRE S CITY, STATE, ZIP PHONE,
a. V-, 1p
DESCRIPTION OF WORK
L0 C� )Cti 1n uv
RESIDENTIAL#DWELLING OFFICE USE ONLY
FLOOR AREA 100��//��pp UNITS w, USE , ,. .•OCC .,,; , TYPF "SQ F1. VALUATION,<«,<
COMMERCIAL ✓ g <4 F ^ c
t
FLOOR AREA
TYPE OF CONSTRUCTION # STORIES ' r
AQMD JOB NUMBER S7 RECEIVED BY OTAL VALUATION:
7 #: �-1
77
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 provi ed i o ect. I have read the Description of Work and verify itis accurate. I agree to comply with all applicable local
ordinances and state laws relating to buildin con *(k.AI authorize representatives of Cupertino to enter the above -identified property for inspection purposes.
Signature of Applicant/Agent: �` Date: 0 T 0 x
SUPPLEMENTAL INFO T ON REQUIRED PRIOR TO ISSUANCE OF DEMOLITION PERMIT
,_OFFICE USL ONLY , ; , ;
Provide Job Number from Bay Air Quality Management District www.baagmd.ore @ 415-749-4762, y PLAN CHECK TYPE
❑ EXPRESS � '�z t ,
Provide three copies of a site plan showing protection for any trees 10" in diameter or more at 3' above grade.
� ❑ STANDARD '`
Provide letter from PG&E (408-725-3325) stating all gas and electric has been disconnected.
❑ LARGE ' +
Planning Dept clearance to verify building is not considered an historical landmark. Allow 10 business days.
❑ MAJOR
'✓Provide letter of clearance of all vermin from a licensed pest control contractor.
i Cs Applicant shall call the Public Works Department at 408-777-3104 and schedule a "habitable dwelling" inspection.
✓Provide Construction and Demolition Recycling Diversion signature form.
_ Commercial Buildings Only: Provide Fire Dept clearance for fire suppression / alarm system review.
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Den:oApp__2016.doc revised 05110/16
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