B-2016-2968 i
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: :
11163 WILKINSON AVE CUPERTINO,CA 95014 4734 356 17 044 CONTRACTOR: PERMIT NO:B-2016-2968
( ) VOEKS INC
SAN JOSE,CA 95125
OWNER'S NAME:. SHANNON I%UCHAEL J AND ELIZABETH TRUSTEE DATE ISSUED:10/25/2016
OWNER'S PHONE:408-674-7261
PONE NO:(408)353-0880
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class C- ¢ Lic.#891491
Contractor VOEKS INC Date 04/30/2018 X BLDG _ELECT X 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:
I herebyaffirm under penalty of er'u RE-ROUTE/REPAIR SEWER LINE TO INSTALL CLEAN OUT PER
P ty p J ry.one of the following two declarations: CUPERTINO SANITARY
i. 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.
z 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.
APPLICANT RTIFiCnmrnim Sq.Ft Floor Area: Valuation $6500.00
1 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 356 17 044
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.
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 )/"te 10/25/2016 Issued by:Abby A ende
Date: l0/25/2016
OWNER-BUR DER 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
m. L 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(Sce.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:10/25/2016
I hereby affirm under penalty of perjury one of the following three declarations:
m. I have and will maintain a Certificate of Consent to self-insure for Worker's ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
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: 1 will
permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
s. 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
material. Additionally,should I use equipment or devices which emit hazardous
shall not employ any person in any manner so as to become subject to the
certificate of t contaminants pl defined h the Bay Area Air Quality Management District I
Worker's Compensation laws of California. If,after making this
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: y
APPLICANT CERTIFICATION Date:10/25/2016
1 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'S DECLARATION
Code,Section 9.18. 1 understand my plans shall be used as public records.
Signature Date 10/25/2016 Licensed
Professional
i
j
GENERAL PERMIT APPLICATION
4 COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION MEP
1.0300 TORRE AVENUE•CUPERTINO,CA 95014-3255
CUPERTINO (408)777-3228•FAX(408)777-3333•building(a cupertino orgmisc
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STREET ADDRESS CITY, STATE,ZZIP FAX
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❑OWNER ❑ OWNER-BUILDER ❑ OWNERAGENT ❑ CONTRACTOR PE CONTRACTOR.AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT
CONTRACTOR NAME VL S� ! '� .A 6� LICENSE NUMBER p n LICEN TYP BUS.LIC#
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COMPANY NAME _ E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF ❑SFD or DUPLEX ❑ MULTI-FAMII,Y PROSECT IN WII.OLAND ❑ YES PROJECT IN ❑YESIS THE BLDG AN ❑YES
BUILDING: F1 COMMERCIAL URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑NO EICI LERHOME? ❑NO
DESCRIPTION OF WORK
Le bu n ,r
TOTAL VALUATION: RE
By my signature below,I certify to each of the following: I am the property owner or authorized ag` t to act on the owner's behalf. I have s
application and the information I have provided is correct. I have read the Description of Work and ven I is accurate. I agree to comply with all applicable o
ordinances and state laws relating to building construction. I authorize representatives of Cupertino to enter the above-identified
/property for inspection purposes,
Signature of Applicant/Agent: Date:
SUPPLEMENTAL INFORMATION REQUIRED of i ICI
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MEPMiscApp 201 L doe revised 06121111