B-2016-2615 i
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR:; PERMIT NO:B-2016-2615
10531 CASTINE AVE CUPERTINO,CA 95014-1310(326 44 036) DEMPSTER
PLUMBING
SAN JOSE„CA 95110
OWNER'S NAME: RAMSAUERALICE J TRUSTEE&ET AL DATE ISSUED:08/30/2016
OWNER'S PHONE:408-738-4656 PHONE NO:(408)597-5877
LICENSED CONTRACTOR'S DELL R TION BUILDING PERMIT INFO:
License Class C-36 Lic.#881509
Contractor DEMPSTER PLUMBING Date 07/31/2018 X BLDG —ELECT X PLUMB
_
I hereby affirm that 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:
REPLACE SEWER LINE&BUILDING DRAIN;INSTALL
I hereby affirm under penalty of perjury one of the following two declarations: CLEANOUT(S),FOUNDATION&PROPERTY LINE
1. I have and will maintain a certificate of consent to self-insure for W rker's
Compensation,as provided for by Section 3700 of the Labor Code, or the
performance of the work for which this permit is issued. E
2.,_,, I have and will maintain Worker's Compensation Insurance as provided for b ? :
6''D Section 3700 of the Labor Code,for the performance of the work fo which this F € G.x. ;.
permit is issued. t e`er ii. .;
Sq.Ft Flooreaaluation:$��00000
APPLICANTCERTIFICATION
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 APN Number: Occupancy Type:
and state laws relating to building construction,and hereby authorize I 326 44 036
representatives of this city to enter upon the above mentioned property or
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 perr nit. WITHIN 180.DAYS OF PERMIT ISSUANCE OR
Additionally,the applicant understands and will comply with all non-poin
source regulations per the Cupertino Municipal Code,Section 9.18, 180 DAYS FROM LAST C D INSPECTION.
Signature' Zzz& Date 08/30/2016 Issued by:
Date:08/30/2016
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(See.7044,Business&Professions Code)
z. I,as owner of the properly am exclusively contracting with licensed Signature of Applicant:
contractors to construct the project(Sec.7044,Business&Professio s Code). Date:08/30/2016
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 forWorker'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 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 fo 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
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 cc tificate of 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 255 , d 5534.
Labor Code,I must forthwith comply with such provisions or this p rmit shall
be deemed revoked. Owner or authorized agent:'-
APPLICANT CERTIFICATION Date:08/30/2016
certify that I have read this application and state that the above inform tion isCONSTRUCTION LENDING AGENCY
correct.I agree to comply with all city and county ordinances and state I aws I hereby affirm that there is a construction lending agency for the performance
relating to building construction,and hereby authorize representatives c f 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. 0 Ve)agree Lender's Name
to save indemnify and keep harmless the City of Cupertino against liabi ities,
judgments,costs,and expenses which may accrue against said City in Lender's Address
consequence of the granting of this permit. Additionally,the applicant u iderstands
and will comply with all non-point source regulations per the Cupertino unicipai ARCHITECT'S be used
a DECLARATION
Code,Section 9.18. I understand my plans shalt be used as public records.
Licensed
Signature Date 08130/2016 Professional
GENERAL PERMIT APPLICATION MEP
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE• CUPE TINO, CA 95014-3255
(408)777-3228'• FAX(408)777-:,333•building(a�cupertino.org
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XPLUMBING ❑MECHANICAL ❑ELECTRICAL ❑MISCELLANEOUS
PROJECT ADDRESS t,95-3/ Cp46-R/165 Ave TAPN 0 l�6 C (�J r' ®�
O-WNER NAME GCS ✓LZ ✓J �� P D v 7 -3O Y E-M&IL
STREET.ADDRESS CITY, STATT�,,ZIP ` F,A7
Gi✓Y A114
CONTACTNAMEh/ PH NE E-M IL
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L lei _ 5$7 a�-r pct � �2 Atm %f
STREET ADDRESS CITY STATE,Z P FAX
❑ 04tR.'ER ❑ OVd?qER-BL-II..DER ❑ OWNER AGENT �CONTRACTO� ❑CONTRACTOR ❑ ARCHITECT ❑ENGLNEER ❑ DEVELOPER ❑ TENANT
CONiTRAC OR LICENSE NUMBER LICENSE T BUS,LIC Too
d ��-' -r2 C La✓N S^® cG
CO ANY NAME MAIL FAX
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STREET ADDRESS CITYT4QIP
ARCHITECT/ENGINEER NAME LICENSE NUMBER �BUS.LIC
COMPANY NAME, MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF FD or Duplex ❑ Multi-FamilyTPRJ�rr INWILDLAIQD PROJECT IN
STRUCTURE: ❑ C011-mercial IINTERFACEAREA ❑ Yes O FLOOD ZONE [I Yes ❑ NO
DESCRIPTION OF WORK �. f4ezk_ sT -WC-Al
TOTAL VALUATION: flo o+�'
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 collect. 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 too buil c Con aut r p esentatives of Cupertino to enter the above-ide tified property for inspection pin-poses.
Signature of Applicant/Agent:_- 'V Date:
i
SUPPLEMENTAL INFORMATIO REQUIRED
.�. , . r.-.OFFICE
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