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B-2016-2620CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: CONTRACTOR: PERMIT NO: B-2016-2620 18763 BARNHART AVE CUPERTINO, CA (375 17 058) ALPINE BUILDER CONSTRUCTION COMPANY INC SAN JOSE, CA 95120 OWNER'S NAME: DUNCAN DEXTER WAND MARTA E R TRUSTEE DATE ISSUED: 08/30/2016 OWNER'S PHONE: 650-245-1641 PHONE NO: (408) 258-6200 LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: License Glass 13 Lic. #838642 Contractor ALPINE BUILDER CONSTRUCTION COMPANY IN-C Date 09/30/2017 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: (N) TEMPORARY POWER POLE (100 AMP); POLE I hereby affirm under penalty of perjury one of the following two declarations; m. I have and willll f 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. z. -� I have and will maintain Worker's Compensation Insurance, as provided for by , Section 3700 the Labor Code, for of the performance of the work for which this permit is issued. Sq. Ft Floor Area: Valuation: $400.00 APPLICANT CERTIFICATION I certify that 1 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 17 058 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 WITHIN 180 DAYS OF PERMIT ISSUANCE OR source regulations per the Cupertino Municipal Code, Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION. Signature C Date $/30/2016 Issued by: AbbyAyende OWNER-BUILDER DECLARATION Date: 08/30/2016 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 m. 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) z. 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: 8/30/2016 I hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER m. 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 z. 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. 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 certificate 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, 2555533, and 25534. Labor Code, I must forthwith comply with such provisions or this permit shall be deemed revoked. 'Ow, Der or authorized agent: n� r» �� /%�`/ 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 Date: 8/30/2016 CONSTRUCTION LENDING AGENCY 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 ARCJEHTECTIS DECLARATION Code, Section 9.18. 1 understand my plans shall be used as public records. Licensed Signature Date 8/30/2016 Professional GENERAL PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT BUILDING DIVISION 10300 TORRE'AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 • build ingOcupertino.org +ov✓i vveefcew✓i-+ r I aan vv>Ci `.y t,Jiu/ I `We/'"04y-(bCOE7 ❑ OWNER ❑ OWNER -BL -II -DER ❑ OR'NTERAGENT pi CONTRACTOR ❑ CONTRACTORAGENT ❑ ARCHITECT ❑ ENGIN-EER ❑ DEVELOPER ❑ TEN.Ai\T CO TRACTOR NAME / LICENSE NUMBER LICENSE TYP BUS. LIC I COMPANYA7 �2 G IRE jJt/1�L7(<'✓C0�1S✓!�(IG�!®11 C,0P*j> AC E-MAIL �/cif/?1'0Ui/41P✓ M9!l •CGM FAX �o$- tG8- 6too STREET ADDRESS$, CITY, STATE. ZIP — ! PHONE Gos urnb4J7 L os�, ea 9�>Za I q0t? g G6s ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS. LIC COi\ZPANY NAME F. -MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE USE OF ❑ SFD or Duplex ❑ Multi -Family PROJECT IN' «TLDLAN-D I PROJECT N STRUCTURE: ❑ Commercial I URBAN INTERFACE AREA ❑ Yes ❑ No FLOOD ZONE ❑ Yes ❑ NO i DESCRIPTION OF WORK Gc VN1D I TOTAL VALUATION: 4h I zInt),ID97 .:RECEIVEDBY,,, f9.I.. By nay signature below, I certify to each of the following: I am the property owner or authorized agent to act on the property owner's behalf. I have read this application and the information I have provided is correct. I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating to uilding%cons ctio I uthorize representatives of Cupertino to enter the above -identified property for inspection purposes. Signature of. Applicant/Agent: /��/ f >r • Date: SUPPLEMENTAL INFORMATI0N REQUIRED d7EPA11iscApp__M1.doe revised 03116111 U PLUMBING U MECHANICAL ® ELECTRICAL []MISCELLANEOUS PROTECT ADDRESS APN n 1 OhVNERNAME � ,i PHONE E-MAIL STREET ADDRESSCITY, 6 n AAve STATE, ZIP FAX cv ea COI\rTACT NAME PHONE my9q SGS E-M,&IL ill u ADDRESS, STREET ADDRESS a CITY, STATE; ZIP r _ o. rr. _ FAX e - e2 -- +ov✓i vveefcew✓i-+ r I aan vv>Ci `.y t,Jiu/ I `We/'"04y-(bCOE7 ❑ OWNER ❑ OWNER -BL -II -DER ❑ OR'NTERAGENT pi CONTRACTOR ❑ CONTRACTORAGENT ❑ ARCHITECT ❑ ENGIN-EER ❑ DEVELOPER ❑ TEN.Ai\T CO TRACTOR NAME / LICENSE NUMBER LICENSE TYP BUS. LIC I COMPANYA7 �2 G IRE jJt/1�L7(<'✓C0�1S✓!�(IG�!®11 C,0P*j> AC E-MAIL �/cif/?1'0Ui/41P✓ M9!l •CGM FAX �o$- tG8- 6too STREET ADDRESS$, CITY, STATE. ZIP — ! PHONE Gos urnb4J7 L os�, ea 9�>Za I q0t? g G6s ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS. LIC COi\ZPANY NAME F. -MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE USE OF ❑ SFD or Duplex ❑ Multi -Family PROJECT IN' «TLDLAN-D I PROJECT N STRUCTURE: ❑ Commercial I URBAN INTERFACE AREA ❑ Yes ❑ No FLOOD ZONE ❑ Yes ❑ NO i DESCRIPTION OF WORK Gc VN1D I TOTAL VALUATION: 4h I zInt),ID97 .:RECEIVEDBY,,, f9.I.. By nay 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 uilding%cons ctio I uthorize representatives of Cupertino to enter the above -identified property for inspection purposes. Signature of. Applicant/Agent: /��/ f >r • Date: SUPPLEMENTAL INFORMATI0N REQUIRED d7EPA11iscApp__M1.doe revised 03116111