B-2016-2638i CITY OF CUPERTINO BUILDING PERMIT
BUILDINGADDRE�SS:
CONTRACTOR:
PERMIT NO: B-2016-2638
10655 CORDOVA RD
CUPERTINO, CA 95014-3911 (342 22 111)
CRAIG A ROGERS
CONSTRUCTION INC
SAN JOSE, CA 95136
OWNER'S NAME:
{ OI LI LYNN AND WU JACK R
DATE ISSUED: 09/01/2016
OWNER'S PHONE:
1408-242-6149
PHONE NO: (408) 978-5484
LICENSED C—C—OR'S DECLARATION TION
License Class 5 Liol. #978553
BUILDING PERMIT INFO:
Contractor (RAIL Al ROGERS CONSTRUCTION INC Date 11/30/2016
X BLDG X ELECT _PLUMB
I
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) TEMP POWER (100 AMP) POLE
I hereby affirm under penalty of perjury one of the following two declarations:
L 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
P ermit is is ued. '
Sq: Ft Floor Area:
Valuation: $500.00
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above
"N Number:
Occupancy Type:
information is correct. I agree to comply with all city and county ordinances
and state laws relati g to building construction, and hereby authorize
342 22111
representatives of this city to enter upon the above mentioned property for
inspection purposesi (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 he app scant understands and will comply with all non -point
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
source regu s p r the Cuperti o nicipal Code, Section 9.18.
180 DAYS FROM LAST C PECTION.
Signature-' Date 09!01/2016
Issued by: MEr–I—SSA N
OWNE DECLARATION-
Date: 09/01/2016
--
I hereby affirm that I am exempt from the Contractor's License Law for one of the
following two reasons:
RE -ROOFS:
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 construct the project (Sec,7044, Business & Professions Code).
Date: 09/01/2016
I hereby affirm under penalty of perjury one of the following three declarations:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
s. 1 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 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.
s. 1 certify thdt 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
i
shall not employ any person in any manner so as to become subject to the
Worker's Uompensation laws of California. If, after making this certificate of
material. Additionally, should I use equipment or devices which emit hazardous
air contaminants as defined by the Bay Area Air Quality Mana ement District I
exemption I become subject to the Worker's Compensation provisions of the
will maintain compliance wit the Cupertino Municipal C e, pter 9.12 and
the Health & Safe ode Sections 255705,255
05, 25 5 34.
Labor Code, I must forthwith comply with such provisions or this permit shall
be deemed revoked.
Owner or authorized agentlA l
APPLICANT CERTIFICATION
Date: 09/01/2016 �-
f
certify that I have read this application and state that the above information is
LE NDING 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 cP nstruction, 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
ARCHITECT'S DECLARATION
and will comply with all non -point source regulations per the Cupertino Municipal
1 understand my plans shall be used as public records.
Cade, Section 9.18.
Signature Date 09/01/2016
Si g
Licensed
Professional
GENERAL PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORREAVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228• FAX (408) 777-3333 building(aDcupertino.org
CUPERT1140
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❑ Own -ER. ❑ OWNER -BUILDER 0w1\ERAGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVEIAPER ❑ TENANT
CONTRACTOR N. E / LICEN LICENS E BUS. LIC
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COMPANY NAME
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STREET ADDRESS
CITY, STATE, ZIP
PHONE,
USE OF
STRUCTURE: ❑
SFD or Duplex
Commercial
0 Multi -Family I PROJECT N IVILDLAND
URBAN INTERFACE AREA
I PROJECT N
❑ Yes No FLOOD ZONE ❑ Yes
DF_SCRIPTIONOF\V)RK
TOTAL VALU'ATIONI
a e
By my signature below,
application and the
ordinances and state
Signahire of Applidant/Agent:
I certify to each
infonnation I have
laws relating to bu
o the following: I am pr r1y owner or authorized agent to act on the property owner's behalf. I have read this
} 'd d is coiTect. Lke read th Description of Work and veiifj, it is accurate. I agree to comply with all applicable local
ns n. I a thorize re resentatives of Cupertino to enter the abo ide�tifie d perry for inspection purposes.
Date:;
SU
V TN AL IIQFORb4ATION REQUIRED
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OFFICBUSEflSLY,,,.�.n
ER THE COITTER
EMPRESS �,
AIIEPAIiscApp=7011. doe revised 03116111