B-2016-2685 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2016-2685
10279 JUDY AVE CUPERTINO,CA 95014-3524(375 08 044) MADERO'S
CONSTRUCTION
MENLO PARK,CA
94025
OWNER'S NAME: WARREN MICHAEL D AND LISAA TRUSTEE DATE ISSUED:09/09/2016
OWNER'S PHONE:408-472-9879 PHONE NO:(650)6794491
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class 5 Lic.#2AE433
Contractor MADERO'S CONSTRUCTION Date 09/30/2018 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 POLE
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
I performance of the work for which this permit is issued.
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
permit is issued. Sq.Ft Floor Area: Valuation:$200.00
APPLICANT CERTIFICATION
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 375 08 044
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. WITHIN,180 DAYS OF PERMIT ISSUANCE OR
Additionally,the applicant understands and will comply with all non-point
source regulations per tho Cupertino Municipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
r
f'Signature Date 09/09/2016 Issued by:Kim Dunbar
Date:09/09/2016
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)
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:09/09/2016
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 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
Health&Safety Code,Section 25532(a)should I store or handle hazardous
s. I certify that in the performance of the work for which this permit is issued I
shall not employ any person in any manner so as to become subject to the air
co Additionally,.should I use equipment or devices which emit hazardous
ir conttao minants 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 25505,25533,and 25534.
Labor Code,I must forthwith comply with such provisions or this permit shall
be deemed revoked. 'Owner or authorized agent
APPLICANT CERTIFICATION Date:09/09/2016
I 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' DEC A ATION
I understand my plans shall be used as public records.
Code,Section 9.18.
Licensed
Signature Date 09/09/2016 Professional
GENERAL PERMIT APPLICATIONMEP
COViMUNITY DEVELOPMiiENTT DEPARTMENT• BUILDING DIVISION
0300 TORRE AVENUE•CUPERTINO,CA 95014-3255
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(408)777-3229• FAX(408)777-3333•building aecuDerino.org m I S
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By my signz ue below,I cer i i to each of the following: I am he propertp ou mer or zuttior-,zed zgenf id'act on the propem owner's s behalf. I Have read this
application and the information I have pre ed is correct. I have read the Description of\Yor zndver)'itis accurzte. I agree to 6outply with all applicable local
ordinances and state laws relatina to b a" nstructior-. I authorize representatives of Cup ,-7no to enter the above-identified prope t},for inspection purposes.
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