B-2016-2571 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS:, CONTRACTOR: PERMIT NO:B-2016-2571
18964 TILSON AVE CUPERTINO,CA 95014-3655(375 09 012) ONSITE CONSTRUX
HALF MOON BAY,CA
94019-4208
OWNER'S NAME: WANG MARY LI HUNG TRUSTEE DATE ISSUED:08/23/2016
OWNER'S PHONE:40$-829-8827 PHONE No;(650)269-5560
LICENSED CONTRA TOR'S DECLARATION BUILDING PERMIT INFO:
License Class 5 Lic.#505588
Contractor ONSITE CONSTRUX Date 10/31/2017 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
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.
-1I I have and will maintain Worker's Compensation Insurance,as provided for by
Section 3700 off the Labor Code,for the performance of the work for which this
permit is issued Sq.Ft Floor Area: Valuation:$250.00
APPLICANT CERTIFICATION
certify that l 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 09 012
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 accrueagainst.said City in consequence the granting of this permit. WITHIN 180 DAYS OF PERMIT ISSUANCE OR
Additionally,the applicant understands and willl comply with all non-point
source regulations er t e Cupertino Municipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
Signa - e Date 08/23/2016 Issued by:Kim Dunbar
Date:08/23/2016
OWNER-BUILDER DECLARATION
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. 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. 1,as owner of the property,am exclusively contracting with licensed Signature of Applicant:
contractors to gonstructthe project(Sec.7044,Business&Professions Code). Date:08/23/2016
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 willmaintain 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: 1 have and willmaintain Worker's Compensation insurance,as provided for by I have read the hazardous materialsrequirements 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
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
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 bejcome subject to the Worker's Compensation provisions of the the Health&Safety Co ections 25505,25533,and 25534.
Labor Code,T Must forthwith comply with such provisions or this permit shall
be deemed revoked .Owner or authorized agen
j APPLICANT CERTIFICAITON Date:08/23/2016
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.
Licensed
Signature Date 08/23/2016
Professional
GENERAL PERMIT APPLICATIONMEF"
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO,CA 95014-3255
iGU ERT[ CU (408)777-3228•FAX(408)777-3333•building(cDcupertino.org
, MISCOihk
❑PLUMBING ❑MECHANICAL nX ELECTRICAL []MISCELLANEOUS
PROJECT ADDRESS 17
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❑ Ow1\*ER ❑ 0y'NER-BUILDER ❑ OWNERAGENr V60NTRACTOR ❑CONIRACTORAGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TEN.ANT
CONTRACTORNAMl Q �, LICENS NUT4BER LICENSE TYPE
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ARCHITECT/ENGW NAME LICENSE NUMBER BUS.LIC r
COMPANTY NAME I F.-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF iX $FD or DUpleX ❑ Multi-Family PROJECT IN WILDLAND I PROJECT IN
STRUCTURE: ❑ iCommercial I URBAN INTERFACE AREA ❑ Yes ❑ NO FLOOD ZONE ❑ Yes ❑ NO
DESCRIPTION'OF WORK �
p, -/ dale
TOTAL VALUATION:
By ury 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 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 struction. I authorize representatives of Cupertino to enter the above-identified property for inspection proposes.
Signature of Applicant/Agent _.,`_ o Date: t 1
t = SUPPLEMENTAL INFORMATION REQUIRED
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