B-2016-3012 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2016-3012
18841 BARNHART AVE CUPERTINO,CA 95014-3601(375 16 054) CNE CONSTRUCTION
INCORPORATION
SAN JOSE,CA 95130
OWNER'S NAME; GRAND SUCCESS LLC DATE ISSUED:10/31/2016
OWNER'S PHONE:408-726-2956 PHONE NO:(408)726-2956
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class is Lie,#1011892
Contractor CNE CONSTRUCTION INCORPORATION Date 03/31/2018 X BLDG X ELECT _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:
TEMP POWER POLE(100 AMP)
" 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
performance of the work for which this permit is issued.
I have and will maintain Worker's Compensation Insurance,as provided for by
L.' Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued. Sq.Ft Floor Area: Valuation:$500.00
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 16 054
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 p he Cupertino Municipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
Sign t re Date 10/31/2016 Issued by:Kim Dunbar
Date:10/31/2016
'ihi I 16 r 1 t_. 1 k
I hereby i firm 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)
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:10/31/2016
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
a. 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 1, , ections 2 v 05,25533,and 25534.
Labor Code,I must forthwith comply with such provisions or this permit shall --tet
be deemed revoked. Owner or authorized agent: .ter►
APPLICANT CERTIFICATION Date:10/31/2016
I certify that I have read this application and state that the above information is CONS 'UQT ON LENDING AGENCY
correct.I agree to comply with all city and county ordinances and state laws I hereby affirm that there isconstruction 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 ARCHITECTS DECLARATION
Code,Section 9.18. I understand my plans shall be used as public records.
Licensed
Signature Date 10/31/2016 Professional
GENERAL PERMIT APPLICATION MEP
,9,,, COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
41'',15, 10300 TORRE AVENUE•CUPERTINO,CA 95014-3255 '
SC
(408)777-3228•FAX(408)777-3333•buildinq(acupertino.orq
CUPERTINO
/3-Mlui -aolz
❑PLUMBING ❑MECHANICAL El ELECTRICAL ❑MISCELLANEOUS
PROJECT ADDRESS i li 7-{ i W o Yl.6 ex`•'�'-j k(f L2- APN P 37 -/( s b 5-/
OWNER NAME /- PHO y E-MAIL / /�o, { � y
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STREET ADDRESS""o`L J toa-i CITY,STATE,ZIP j p FAX
CONTACT NAME ....„ J PHONE \
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STREET ADDRESS - CITY,STATE,ZIP FAX
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❑OWNER 0 OWNER-BUILDER 0 OWNER AGENT 0 CONTRACTOR W,CONTRACTOR AGENT 0 ARCHITECT 0 ENGINEER 0 DEVELOPER 0 TENANT
CONTRACTOR NAME LICENSE NUMBERp� LICENSE TYPE BUS.LIC# C2 7
�. V Co�7 S a�9'vi. / I o f f.g ! y
COMPANY NAME E-MAIL FAX
COT eC-0/1,9 67, d t I t Y1''I
STREET ADDRESS - CITY,STATE,ZIP , PHONE
ARCHITECT/ENGINEER NAME DP ENSE NUMBER BUS.LIC#
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF 0 SFD or DUPLEX 0 MULTI-FAMILY PROJECT IN WILOLAND 0 YES PROJECT IN ❑YES IS THE BLDG AN 0 YES
BUILDING: '- ❑COMMERCIAL URBAN INTERFACE AREA ❑ NO FLOOD ZONE 0 NO EICHLER HOME? 0 NO
DESCRIPTION OF WORK
Ta-
TOTAL VALUATION: B g i �;
By my signature below,I certify to each of the fo t ing: 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 prod.-i i•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 rel.fing to r :i mg 4 n a. on. a -iz IS:presentatives of Cupertino to enter the above-Identified property for inspection purposes_
Signature of Applicant/Agent: /r Date: (0(/'3 I ! ..?- 9/4 6
L,PI6LEMENTAL INFORMATION REQUIRED ''�
OEFlc DISE ONLY
-'. " o ER-TIDE eOTJN aR ,.. ..
F Iii EXPRESS ,
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l• `MEPMiscA 2011.doc revised 06/21/11
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