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B-2016-2433CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: CONTRACTOR: PERMIT NO: B-2016-2433 10270 CALVERT DR CUPERTINO, CA 95014-3808 (375 18 019) AN KY CONSTRUCTION INC SAN JOSE, CA 95139 OWNER'S NAME: LEUNG HOI SAN DATE ISSUED: 08/01/2016 OWNER'S PHONE: 408-807-7971 PHONE NO: (408) 234-2673 LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: License Class GENERAL BUILDING CONTRACTOR Lic. #$44$56 ContractorAN KY CONSTRUCTION INC Date 06/30/2018 X BLDG X ELECT —PLUMB I 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: INSTALL TEMPORARY POWER POLE 100AMP 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 r performance of the work for which this permit is issued. -hive 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: $500.00 APPLICANT CERTIFICATION l certify that 1 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 18 019 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 oe granting of this permit. WITHIN 180 DAYS OF PERMIT ISSUANCE OR Additionally, the applicant understands and wi bcomply with all non -point source regulations per th ertino Muni 0 1 Code, Section 9.18. 180 DAYS FROM LAS ECTION. Signature,,`r' Date 08/01/2016 Issued by: MELI Dater 08/01/2016 OWNER -BU !IER DEC TON I hereby affirm that I a 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 a roof 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) z. 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: 08/01/2016 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 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. I will permit is issued. maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the 3. 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 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 Municip Code, C9hapter 9.12 and exemption, I become subject to the Worker's Compensation provisions of the the Health &Safety Code, Sections 2 05 533, a d 25534. Labor Code, I must forthwith comply with such provisions or this permit shall f be deemed revoked. _.,w._. Owner or authorized agent: = Z APPLICANT CERTIFICATION Date: 08/01/2016 / I certify that I have read this application and state that the above information is CONSTRUCT LEND , A EN -Y I hereby affirm that there is a co ruction le 'ding agency for the performance correct. I agree to comply with all city and county ordinances and state laws N relating to building construction, and hereby authorize representatives of this city of work's for which this permit' 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. i understand my plans shall be used as public records. Licensed Signature Date 08/01/2016 Professional_ CUPERTINO GENERAL PERMIT APPLICATION mmm E P COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 • buildinp(a�cupertino.oro M I A r. r3�- tING MECHANICAL NF.T.F('TRT(-AT ri 7, ATc rrT;TT AT,TcnT TO PROJECT ADDRESS ef GAL tl�G -r P. „ill\ APN r W ONERNAME JJA1-116 FX ,1 L A/44— PHONE ®�� ( ADDRESS 7^��9 p �J �/ cif (/ /� 2 CITY, STATE, ZIPSpFZ/ C. --C I;vo tNLAti/STREET CONTACT NAME � PHONE (j7 / E-MAIL i l;5 w STREET ADDRESS CITY, STATE, ZIP FAX ❑ owNER ❑ owNER-BUIIAER ❑ OWNTERAGENT 19 CONTRACTOR ❑ CONfRACTORAGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NA /Y 17yLICENSE NUMB LICENSE TYPE BUTS. LIC n� COMPANY NAME$MAIL STREET ADDRESS CITY, STATE, TA E,ZI ZI !I3 P ® E x N`f1 m2 , 7-673 ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS. LIC COMPANY NAME E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE USE OF ElSFD Or Duplex Multi -Family STRUCTURE: ❑ Commercial PROJECT IN Vv7LDLAND URBAN INTERFACE AREA ❑ Yes NO PROJECT IN FLOOD ZONE ❑ Yes I' NO / DESCRIPTION OF WORK I' TOTAL VALUATION: �v /7i I PED B3 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 ha read the Description of NWork and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating to building constru utho resentatives of Cupertino to enter the above-iden `fled property for inspection purposes. Signature of AppIicant/Agent: Date: �� zo INFORMATION REQUIRED MEPMiscApp_2011.doe revised 03116111