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B-2016-3128 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2016-3128 20173 APPLE TREE LN CUPERTINO,CA 95014-2001(316 33 095) DUCOTE ELECTRIC INC SARATOGA,CA 95070 OWNER'S NAME: ARPAT GUVEN B AND TAHAEI ANOUSH CA DATE ISSUED:11/15/2016 OWNER'S PHONE:408-313-4601 PHONE Nth(408)873-2300 LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: License Class C10 Lic.#588703 Contractor DUCOTE ELECTRIC.INC Date 02/28/2018 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: I hereby affirm under penalty of perjuryone of the following two declarations: PANEL UPGRADE(200 AMP) 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. 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 permit is issued. Sq.Ft Floor Area: Valuation:$4000.00 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 316 33 095 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 Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION. G Signature ��� Date 11/15/2016 Issued by:Kim Dunbar Date:11/15/2016 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 roofmg 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:11/15/2016 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 3. 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 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:11/15/2016 � a 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'S DECLARATION Code,Section 9.18. I understand my plans shall be used as public records. Licensed Signature 7. L Date 11/15/2016 professional GENERAL PERMIT APPLICATION MEP �� COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION �. , 10300 TORRE AVENUE•CUPERTINO,CA 95014-3255 CUPERTINO (408)777-3228a FAX(408)777 3333•building(�cupertino.orqM IISC /3---2.0 -3/„?sr ❑PLUMBING ❑MECHANICAL ELECTRICAL IS LA NEOUS PROJECT ADDRESS / q /� p y� °y C / �p b/! /3 / 1 ! P� G / p z f� G.✓S e APN# 3/‘—33—Q OWNER NAME ,,{{ (` / y�yJ j �y (� r� J / A/YOZI,SH/1 1 /t/7/1 E! PHONF�ted ` t '�G� � E MAIL STREET ADDRESS 2 o 17 A At.,41'"7izet" CITY,STATE,ZIP zeFAX CONTACT NAME l/ fe eV PHONE kph �vc yak--..-i4.7— %��- E �g GWRVC,A41:die2- p STREET ADDRESS CTYSTATEZIP FAx P/ / 11 5'g / rf R OWNER 0 OWNER-BUILDER 0 OWNER AGENT 0 CONTRACTOR 0 CONTRACTOR AGENT 0 ARCHITECT 0 ENGINEER 0 DEVELOPER 0 TENANT CO COR NAME j LI�CEENSSEE NUMBER y LICENSE TYPE BU L r/ �/S. Irl �%O'�✓.. G. ��C 1�/"L' J 6 �s3'1 g�J1 COAME f� Y C l� �d B �'�/'') j1 / y�f /// if/4 �✓ EMAIL /er " o(SreLi'f/,A,i /e-P,y FAX STREE ADI RESS C Y,STATE,Z P 1 /d'/ f'v•2 cr iz 'r_e� A te) v� w; cs„si : z.,?:z.s� ARCHITECT/ENGINEER NAME /1/4".r V LICENSE NUMBER / BUS.LIC# COMPANY NAME E-MAIL �(`/ FAX STREET ADDRESSCITY,CITY,STATE,ZIP PHONE USE OF I•J`AFD or DUPLEX 0 MULTI-FAMILY PROJECT IN WILDLAND 0 YES PROJECT IN 0 YES IS THE BLDG AN 0 YES BUILDING: 0 COMMERCIAL URBAN INTERFACE AREA ❑ NO FLOOD ZONE 0 NO EICHLER HOME? 0 NO DESCRIPTION OF WORK fP v2 rte . .1 ul! f/ �/Y.4-Ve j".14" /r'�14 s;11,/64/� P01--," I� 4� �</ek- ?! 2c o TOTAL VALUATION.44{-0(3(D By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on e property owner's behal£ Ihave read this application and the information I have provided is 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 relating t build nstiupt�gn. I auth9r ze rep tives of Cupertino to enter the above-identified property for inspection purposes. Signature of Applicant/Agent: ��V✓`` �r// Date: //`/'c)"'/4 SUPPLEMENTAL INFORMATION REQUIRED OFFICE USE;ONLY' O(?ER Tim COONTER 0`EXPRESS r ❑ STANDARn V` ©, LARGE,` 0 MAJOR MEPMiscApp_2011.doc revised 06/21/11