B-2016-2502CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS:
10553 LA RODA DR CUPERTINO, CA 95014-4430
CONTRACTOR:
PERMIT NO: B-2016-2502
(369 33 024)
RE-CREATION
CONSTRUCTION INC
SAN JOSE, CA 95129
OWNER'S NAME: WANG STANLEY AND YANG YA-LING
DATE ISSUED: 08/12/2016
OWNER'S PHONE: 408-505-3267
PHONE NO: (650) 868-8245
LICENSED CONTRACTOR'S DECLARATION
BUILDING PERMIT INFO;
License Class $ Lic. #945926
Contractor BE -CREATION CONSTRUCTION INC Date 44/30/2018
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:
TEMP POWER 100AMP POLE
I hereby affirm under penalty of perjury one of the following two declarations;
1. Ihave 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.
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
permit is issued.
Sq. Ft Floor Area:
Valuation: $500.00
APPLICANT ANT RTIFI ATION
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
369 33 024
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.
Additionally, the applicant understands and will comply with all non -point
WITFIIN 180 DAYS OF PERMIT ISSUANCE OR
source regulations per the Cupertino Municipal Code, Section 9.18.
180 DAYS FROM LAST CALLED INSPECTION.
,Signature Date 08/12/2016
Issued by: Kim Dunbar
OWNER -B iiT D •RDELARATION
Date: 08/12/2016
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 a roof is
1. 1, 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. L as owner of the property, am exclusively contracting with licensed
Signature of Applicant:
contractors to construct the project (Sec.7044, Business & Professions Code).
Date: 08/12/2016
I hereby affirm under penalty of perjury one of the following three declarations:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
1. 1 have and will maintain a Certificate. of Consent to self -insure for Worker's
A
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. 1 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(x) 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
Worker's Compensation laws of California. If, after making this certificate of
air contaminants as defined by the Bay Area-Alr Quality Management District I
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, Sections 25505, 25533, and 25534.
Labor Code, I must forthwith comply with such provisions or this permit shall
be deemed revoked.I.,
Owner or authorized agent-
gent
APPLICANT
APPLICANT CERTIFICATION
Date: 08/12/2016
I certify that I have read this 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.
Signature Date 08/12/2016
Licensed
Professional
GENERAL PERMIT APPLICATION MEP
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 m Us Apmkk
(408) 777-3228 • FAX (408) 777-3333 • building(a)cupertino.oM
CLIPERTINQ
IVI
7PLUMBING 71\4EC1-LANICAi, fdf IFT.Ff -rRTf`bl 1 ` I1,arcrFT T A1.TRn c
PROJECT ADDRESS I- ti 7J S-3 Pk, APNII
(P
t�+
ONERNAME // PHONE '
E-12AIL
STREET ADDRESS / �� CITY, STATE, ZIP F4ti
p !: �/
CONTACT NAME
I PHONE -MAIL
1p
STREET:ADDRESS
CITY, STATE, ZIP
FAX
❑ ON R`NER ❑ OWNER -BUILDER ❑. OWNER AGENT ILH CONTRACTOR ❑ CONTRACTOR AGENT ❑. ARCHITECT ❑ ENGLNEER ❑ DEVELOPER ❑ TE' ANT
CONTRACTOR NAME
LICENSE1\MIBER
LICENSETYPE 13
BUS. LIC'
COA4P.AI\YNAME /%�^�
lir �8
STREET ADDRESS ,%% // 1� /
CIT STATE, ZIP
PHONE-
/ ' b a f �� "
--,—I
ARCHITECT/ENGINEER NAME LICENSE NUMBER
BUS. LIC r
COMPANY NAME
E-MAIL
FAX
ti
STREET ADDRESS -
CITY, STATE, ZIP
PHONE
USE OF XSFD orDUPLEX ❑ MULTI•FAMILY PROSECT LN WILDLAND ❑ YES PROJECT AT ❑ YES
IS THE BLDG AN ❑ YES
BURDING: El COMMERCIAL I URBAN INTERFACE AREA NO FLOOD ZONE NO
EICHLERHOME? NO
DESCRIPTION OF FORT
/
1 0 0
TOTAL VALliATION: RECEIVED 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 ovner'S behalf. I have read this
application and the infonnation I have provided 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 to building construction. I authorize representatives of Cupertino to enter the abov -identified property for inspection purposes.
/
Signature of Applicant�Agent: Date: .2
SUPP MEN AL INTFORMATION REQUIRED
OFFICE iJSE'OhLI
4 y✓
:i� ' '
r
01 ER THE COtI\TER ,
. ❑ EMPRESS ti �
U2
z
,4fEPA11iscAPP_?011.doe revised 06121/11