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B-2016-2611 CITY OF CUPEIkTINO BUILDING PERMIT BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2016-2611 10440 PINEVILLE AVE CUPERTINO,CA 95014-4523(369 13 038) A SEWER EXPERT PLUMBER INC HAYWARD,'CA 94541 OWNER'S NAME: MILLER MICHAEL O AND STELLA C TRUSTEE DATE ISSUED:08/29/2016 OWNER'S PHONE:510-280-4698 PHONE NO:(510)209-9511 LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: License Class C-36 Lic.# 110 2033 Contractor SEWER EXPERT PLUMBER INC Date 03/31/2018 X BLDG —ELECT X PLUMB I hereby affirm that I am licensed under the provisions of Chapter 9(coultiencing _MECH X RESIDENTIAL_COMMERCIAL with Section 7000)of Division 3 of the Business&Professions Code and th it my license is in full force and effect. JOB DESCRIPTION: REPLACE WATER MAIN SERVICE I hereby affirm under penalty of perjury one of the following two declarations: 1. 1 have and will maintain acertificate of consent to self-insure for Worker's Compensation,as provided for by Section 3700 of the Labor Code, or the performance of the work for which this permit is issued. z*..tio. I have and will maintain Worker's Compensation Insurance,as Prov ded for by 3700.of the Labor Code,for the performance of the work fo which this ermit is issued. Sq.Ft Floor Area: Valuation:$1800.00 APPLICANT CERTMCATION 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 369 13 038 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 whi h PERMIT EXPIRES IF WORK IS NOT STARTED may accrue against said City in consequence of the granting of this per. it. WITHIN 180 DAYS OF PERMIT ISSUANCE OR Additionally,the applicant understands and will comply with all non-poin source regulations per the CupertinoMunicipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION. ,Signature Vi 1 1 U l U Date 08/29/2016 Issued by:Kim Dunbar ti. Date:08/29/2016 OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for o rie 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 so a 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. a 0Business y, ooc a Iasownerofthe ProPertYamexclusivelYontractin with license Signature ofApplicant: contractors to construct the project(Sec.7044,'Busincss&Professk ns Code). Date:08/29/2016 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 2. I have and will maintain Worker's Compensation Insurance,as pro 'ded 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 maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the permit is issued. Health&Safety Code,Section 25532(x)should I store or handle hazardous s. I certify that in the performance of the work for which this permit i issued I shall..not employ any person in any manner f as to become subject tthe material. Additionally,should I use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Manageme8t District I Worker's Compensation laws of California. If,after making this c 'ficate of will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and exemption,I become subject to the Worker's Compensation provisi Dos of the the Health&Safety Cote,Sections 25505,255331 d 25534. Labor Code,I must forthwith comply with such provisions or this I ermit shall be deemed revoked. C Owner or authorized agent: APPLICANT CERTIFICATION '"' Date:08/29/2016 certify that I have read this application and state that the above information is CONSTRUCTION I ENDINGAGENCY 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. e)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 L nderstands ARCHITECT'S DECLARATION and will comply with all non-point source regulations per the Cupertino Municipal I understand my plans shall be used as public records. Code,Section 9.18. Licensed Signature Date 08_ 9/20le Professional GENERAL PERMIT APPLICATION MEP COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 10300 TORRE AVENUE CUPERTINO,CA 95014-3255 1 S AdIM& (40:8)777-3228' FAX(408')777-12,333 building(a)cupertino.org +CUPERTIt�iC� PLUIMBING ❑mEmANICAL ❑ELECTRICAL ❑MISCELLAI�TEOUS v V PROJECT ADDRESS APN r RVq ppp p it / s OWNER NAME 41(\� � PHONE q E-MAIL STREET ADDRESS 1 e ITY, STATE,ZIP CONTACT NAME '"7�� r E-MAIL llJJ STREET ADDRESS ITY,STATE,ZIPi �� FAX YJ_115.1�'INER ❑ ORR.NER-i3uTLDER ❑ OwNERAGENT ❑ CON'TRACTO ❑COI.'TRACTORAGF-NT El ARCHITECT ❑ENGMEER ❑ DEVELOPER IV-TENANT CONTRACTOR NAME t LICENS NUMBER ! LICENS TYP BUS.LICA COMPANYNAME {/ #' � E-MAIL v w FAX STREET ADDRESS ` ITY,STATE.ZIP � r• 1T ,Y_� �}, PHONE ARCHITECT(ENGINEERNAME LICENS NUMBER BUS.LIC t COI\4PA2\TY NAME :MAIL _ FAX STREET ADDRESS CITY,STATE,ZIP PHONE USE OF ❑ SFD Or Duplex ❑ Multi-Family PROJEC TT IN NVILDI.ANZD I PROJECT IN STRUCTURE: ❑ Commercial I URBAN INTERFACE AREA ❑ Yes ❑ No FLOOD ZONE ❑ Yes ❑ No � 0 1 DESCRIPTION OF WORK TOTAL VALUATION: RECEIVED BY By my signature below,I certify to each of the following: I am the proper owner or authorized agent to act on the property owner's behalf. T 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 building construction. I authorize rep esentatives of Cupertino to enter the above-identified property for inspection purposes. Signature of Applicant/Agent: ' 1 Date: SUPPLEMENTAL INFORMATION REQUIRED ` AFFICE DSE ONLY„ F a- ��❑X01 ER THE-COtiIvTER E EXPRESS R ms` s D ST4NDARD U r � z LARGE r rx D I\ZASOR h7ERAlliscAp12011.doc revised 03/16111