B-2016-3124 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2016-3124
10525 MADRONE CT CUPERTINO,CA 95014-6578(342 61 038) PAYLESS WATER
HEATERS&
PLUMBING INC
VALENCIA,CA 91355
,OWNER'S NAME: BERG CURT G AND SHIELA M DATE ISSUED:11/15/2016
OWNER'S PHONE:650-967-0271 PHONE NO:(661)775-2979
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class C36 Lic.#836216
Contractor PAYLESS WATER HEATERS&PLUMBING INC Date 08/31/2018 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:
(N)75 GAL WATER HEATER-GARAGE
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
v-.
performance of the work for which this permit is issued.
£ I have and will maintain Worker's Compensation Insurance,as provided for byJ
Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued. Sq.Ft Floor Area: Valuation:$2394.00
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 342 61 038
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 li ilities,judgments,costs,and expenses which PERMIT EXPIRES IF WORK IS NOT STARTED
may accrue against said inconsequence of the granting of this permit. WITHIN 180 DAYS OF PERMIT ISSUANCE OR
Additionally,the applicant derstands and will comply with all non-point
source regulations per th upertino Municipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
i
Signature Date 11/15/2016 Issued by:Kim Dunbar
I Date:11/15/2016
OWNER-BUILDER D _-•- ;1N
I hereby affirm that I am ex/,t io ii 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 Munici al 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)shou store or handle hazardous
shall not employ any person in any manner so as to become subject to the material.Additionally,should I use equipmen or evices which emit hazardous
air contaminants as defined by the Bay Area ' uality Management District I
Worker's Compensation laws of California. If,after making this certificate of will maintain compliance with the Cupertinocipal Code,Chapter 9.12 and
exemption,I become subject to the Worker's Compensation provisions of the the Health&Safety Code,Se tion, ,5505,25533,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 lir
I certify that I have read this application and state that the above information is I 4 Y , .
correct.I agree to comply with all city and county ordinances and state laws I hereby affirm that there is a construction) g agency for the performance
relating to building construction,and hereby authorize representatives of this city of work's for which this permit is issued(S:"". 197,Civ C.)
to enter upon theabove 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 Date 11/15/2016 Professional
GENERAL PERMIT APPLICATION MEP
t#1111:01:.›..,
• COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO,CA 95014-3255
• s (408)777-3228• FAX(408)777•-3333•buildinci cupertino.orq I S C -
CUPERTINO
rL__I 7 6-2016,--312V
PLUMBING MECHANICAL El ELECTRICAL p El MISCELLANEOUS
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PROJECT ADDRESS 1® t°'l A J Y V 7/ APN# 3 tel
OWNER NAME,�j ONP E-MAIL
STREET ADDRESS r
�� Se TE,ZIP cv-` 'C_7 FAX
CONTACT NAME '�
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STREETADDRESS�1,, q. P ej Y STATE,,rn _ A (c t2
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❑OWNER ❑ OWNER-BUILDER 0 OWNER AGENT CONTRACTOR 0 CONTRACTOR AGENT 0 ARCHITECT 0 ENGINEER 0 DEVELOPER 0 TENANT
CONTRACTOR NANVIA
® LICE RtINIAtkrgr4 2"1(e' LICENSE TYPt,),3 BUS.LIC# 114,
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COMPANY NAME 7 E-MAIL FAX
STREET ADDRES t9 svLivitti u,STA.E,ZIP QNE
eyNc
ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC#
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIPPHONE
USE OF ni SFD or DUPLEX 0 MULTI-FAMILY PROJECT IN WILDLAND 0 YES PROJECT IN 0 YES IS THE BLDG AN 0 YES
BUILDING: ❑COMMERCIAL URBAN INTERFACE AREA 0 NO FLOOD ZONE ❑NO EICHLERHOME? 0 NO
DESCRIPTION OF WORK
® ' to d - Vit, c-
TOTAL VALUATION: ?9 L �• RECEXVEL7
By my signature below,I certify to each of the ill. 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 provided is.orrect. 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 to build' _ y. ction. I authorize representatives of Cupertino to enter the above-identifijd prope for inspection purposes.
Signature of Applicant/Agent: Date: (/ ( r (
SUPPLEME S 1 'IINFORMATION REQUIRED
OEJCJ,
USE ONLY
W �❑ •OVER lib:COUNTER
El ,EXPRESS
0'rST�N77ARD
d; LARGE
Q MAJOR''
MEPMiscApp_2011.doc revised 06/21/11