B-2016-2950 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS CONTRACTOR: PERMIT NO:B-2016-2950
631 STENDHAL IN CUPERTINO,CA 95014-4655(375 42 028) ALL VALLEY
PLUMBING INC
FREMONT,CA 94539
OWNER'S NAME: JASMAN ROBERT J SR TRUSTEE DATE ISSUED:10/20/2016
OWNER'S PHONE:408-252-2635 PHONE NO:(510)661-9095
LICENSED ONT TOR' R TION BUILDING PERMIT INFO:
License Class S,W Lie.#794890
Contractor ALL VALLEY PLUMBING INC Date 02/28/2017 X BLDG —ELECT X PLUMB
MECH X RESIDENTIAL_COMMERCIAL
I hereby affirm that I am licensed under the provisions of Chapter 9(commencing
with Section 7000)of Division 3 of the Business&Professions Code and that my
license is in full force and effect. JOB DESCRIPTION:
REPLACE 50 GAL WATER HEATER,SAME LOCATION
I hereby affirm under penalty of perjury one of the following two declarations:
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.
z.� 'I have and will maintain Worker'sCompensation 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:$750.00
.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 APN Number: Occupancy Type:
and state laws relating to building construction,and hereby authorize 375 42 028
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 the Cupertino Municipal pection 9.18. 1$0 DAYS FRO INSPECTION.
Signet Date 10/20/2016 Issued by:ME
Date: 10/20/2016
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of the. RF.-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)
2. 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:10/20/2016
I hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
r: 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. 1 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. 1 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,Sectio 505,25533,and 2 4
Labor Code,I must forthwith comply with such provisions or this permit shall
be deemed revoked. Owner or authorized a e
APPLICANT CERTIFICATION Date:
1 certify that I have read this application and state that the above information is t'ONSTRUC OTI N 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 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 10/20/2016 Professional
GENERAL PERMIT APPLICATION MEP
COMMUNITY DEVELOPMENT DEPARTMENT BUILDING DIVISION
10300 TORRE AVENUE CUPERTINO,CA 95014-3255
CUPERT'WC] (408),777-3228• FAX(408}777-3333-buiidingcDcupertino.org MISC
G�FLUMBING ❑MECHANICAL []ELECTRICAL MISCELLANEOUS
PROJECT ADDRESS
APN# 3 ��` 't Z ! 0 2-9
OWNER NAME ^�- PHONE J E-MAIL -
- w
Z JSTREET ADDRESSCITY,STATE,ZIP FAX
6.31 [ $1r
CONTACT NAME I PHONE r E-MAIL
f+r? ca�SOA
f v lo—j&G'I-9 0�'SA �'T �: illrs I /" g �v C4.� ca�M
S T ADDRES
u� CITY,STATE,ZIP FAX
❑OWNER ❑ OWNER-BUILDER ❑.OWNER AGENT E CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER :❑TENANT
CONTRACTOR NAME - LICENSE NUMBERLICENSE TYPE BUS.LIC#
--7'q L4 S�0 3 23015-
-COMPANY NAME E-MAIL FAX
ALL a _ t -4 o4 '�
STREET ADDRESS - CITY,STATE,ZIP PHONE
3-1,A S -. :' -r A-)t' GA '-f 53 07 0
ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC#
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF f or DUPLEX ❑ PROJECT IN WILDLAND ❑ YES PROJECT IN ❑YES IS THE BLDG AN ❑YES
BUII.DING: ❑COMMERCIAMULTI-FAMII.YL 7 URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑NO. EICHLER HOME? ❑NO
DESCRIPTION OF WORK , _
t1 LrA l — c - 2 .LLL
TOTAL VALUATION: C w:'_
By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on th e e a ave read this
application and the information I have provided is correct. I have read the Description of Work and verify it is accurate. T agree tj comply with all applicable local
ordinances and state laws relating to building c uction. I author resentatives of Cupertino to enter the above-identified property for inspection purposes.
Signature of Applicant/Agent: Date: 6t� 'I
SUPPLEMENTAL INFORMATION REQUIRED OMCE,USKONLY
W -THE-COUNTER.
��E :."❑"EXPRESS'
TANDARD -
a
JILARGE,
'❑' MA70R;
MEPMiscApp_2011.doc revised 06/21/11
azo CERTIFICATE OF LIABILITY INSURANCE CE 0 DATE 0/203.6
/YYYY)
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: Ilf the certificate holder is an ADDITIONAL INSURED,the policy(tes)must be endorsed. if SUBROGATION IS WAIVED;sub ect to
the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the
certificate holder in lieu of such endorsement(s), T
PRODUCER %, 1-800-409-8958
Vensurance CONTACT
NAME:
-PHONE
4140 8. Baseline Rd. FAX
Suite 201 E-MAIL AIC No:
Mesa, AZ 85206 AOOREss:
INSURER S,AFFORDING COVERAGE
NAiC#
INSURED INSURERA: SECURITY NATL INS CO
Vensure HR, Inc. L/C/F CSLC Staffing 19879
INSURER B
9155 Archibald Ave. INSURER C:
INSURER D
Rancho Cucamonga, CA 91730, EINSURER
E:
COVERAGES CERTIFICATE NUMBER: 47415592 F:
THIS A TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAREVIMED ABOVESION B OR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
IOD
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS,
ILTR TYPE OF INSURANCE ADDL S BR
POLIGY NUMBER MMIDDYIYYEFF MMIDDY EXP
GENERAL LIABILITY LIMITS
COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $
CLAIMS-MADE ❑OCCUR PREMISES/Ea occurrence) $
MED EXP(Any one person) $
PERSONAL&ADV INJURY
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $
POLICY PRO. LOC PRODUCTS•COMP/OP AGG $
AUTOMOBILE LIABILITY I $
ANY AUTO
COMBINED SINGLE LIMIT
Ea accident
ALL OWNED SCHEDULED BODILY INJURY(Per person) $
AUTOS AUTOS
HIRED AUTOS
NON-OWNED BODILY INJURY(Per accident) $
AUTOS PROPERTY DAMAGE
Per accident $
UMBRELLA LIAR OCCUR $
EXCESS LIAR CLAIMS-MADE EACH OCCURRENCE $
DED RETENTION$ AGGREGATE $
A WORKERS COMPENSATION SWC1099382 i S
AND EMPLOYERS'LIABILITY YIN 02/01/1 02/03/17 X WCSTATU• 0TH-
ANY PROPRIETORiPARTNERiEXECUTIVE
(Mandatory
ER EXCLUDED? NIA E.L.EACH ACCIDENT $ 1000000
(Mandatory in NH)
Des,dIPTIO uFO E.L.-0ISEASE--A EMPLOYE $ 1000000
DESCRIPTION OF OPERATIONS below
E.L.DIS EASE•POLICY LIMIT $ 1000000
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,Ii moro space is required)
Worker' Compensation coverage is provided by contract to co-
CSLC Staffing, Inc. employees of Vensure FIR, Inc, and
For employees. of CSLC Staffing working under the direction of; ALL VALLEY PLUMBING
Waiver of Subrogation in favor of the certificate holder
CERTIFICATE HOLDER CANCELLATION
Allvalley Plumbing Inc. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
3345 Seldon Ct. #B THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED iN
Fremont Ca. 94539 ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
USA T1151
'
ACORD
O®D 25(2010105) The ACORD name and logo are registered marks o ACORD10ACORD CORPORATION. Ail rights reserved.
Y
47415592