B-2016-2505CITY OF CUPERTINO BUILDING PERMIT
BUH,DINGADDRESS: CONTRACTOR: PERMIT NO: B-2016-2505
19479 ROSE.MARIF PL APT 1 CUPERTINO, CA 95014-3452 (375 01 007) COHEN DAVID N ET
AL
19479 ROSEMARIE PL
CUPERTINO, CA
95014-3452
OWNER'S NAME: COHEN DAVID N ET AL I I DATE ISSUED: 08/15/2016
OWNER'S PHONE: (650)766-9160 IPHONENO: None
LICENSED CONTRACTOR'S DECLARATION
License Class Lic. #
Contractor COHENDAVID N ET AL Date
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.
hereby affirm under penalty of perjury one of the following two declarations:
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.
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
permit is issued.
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
and state laws relating to building construction, and hereby authorize
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
may accrue against said City in consequence of the granting of this permit.
Additionally, the applicant understands and will comply with all non -point
source regulations per the Cupertino Municipal Code, Section 9.18.
Signature Date 08/15/2016
BUILDING PERMIT INFO:
BLDG X ELECT _ PLUMB
MECH X RESIDENTIAL _ COMMERCIAL
JOB DESCRIPTION:
UPGRADE SUB PANEL (100 AMP);SAME LOCATION (UNIT 1)
Sq. Ft Floor Area: Valuation: $2000.00
APN Number: Occupancy Type:
375 01 007
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
Issued by: Kim Dunbar
Date: 08/15/2016
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
i. 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)
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: 08/15/2016 .
I hereby affirm under penalty of perjury one of the following three declarations:
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.
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.
s. I certify that in the performance of the work for which this permit is issued, I
shall not employ any person in any manner so as to become subject to the
Worker's Compensation laws of California. If, after making this certificate of
exemption, I become subject to the Worker's Compensation provisions of the
Labor Code, I must forthwith comply with such provisions or this permit shall
be deemed revoked.
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 and state laws
relating to building construction, and hereby authorize 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 may accrue against said City in
consequence of the grantinof this permit. Additionally, the applicant understands.
and will comply with all d' -point source regulations per the Cupertino Municipal
Code, Section 9.18.
L
jnature Date 08/15/2016
TO BE CLASS "A"
HAZARDOUS MATERIALS DISCLOSURE
I have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533, and 25534. I will
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
Health & Safety Code, Section 25532(a) should I store or handle hazardous
material. Additionally, should I use equipment or devices which emit hazardous
air contaminants as defined by the Bay Area Quality Management District I
will maintain compliance with the Cupertinfl
u__cipal Code, Chapter 9.12 and
the Health & Safety Code, Sectio 125505,25533, and 25534.
Owner or authorized agent:. f✓
Date: 08/15/2016
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance
of work's for which this permit is issued (Sec. 3097, Civ C.).
Lender's Name
Lender's Address
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Licensed
CUP ERTINO
GENERAL PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228 - FAX (408) 777-3333 • build! nona cuoertino.orp
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B v my signature below, I certify to each of the fo Ling: I am the property owner or autho ' -_ent to act n the prop. -M, ow a t. I have read this
application and the information I have provide ` s correct. I have read the Description of IA,ork and verify i _ ; ith all applicable local
d lawspatina to builain cons con. I authorize representatives of Cupertino to enter thea ove-r e tt .roperi}r for inspection purposes.
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