Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
B-2016-3190
CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2016-3190 19479 STEVENS CREEK BLVD STE 110 CUPERTINO,CA 95014(316 20 112) MAIN STREET CUPERTINO AGGREGATOR LLC 2882 SAND HILL RD STE 241 MENLO PARK CA 94025-7057 OWNER'S NAME: MAIN STREET AGGREGATOR DATE ISSUED:12/01/2016 OWNER'S PHONE:408-777-3081, PHONE NO:None I,ICFNSFD CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: License Class Lic.# Contractor MAIN STREET CUPERTINO AGGREGATOR LLC Date X BLDG X ELECT _PLUMB MECH_RESIDENTIAL X 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: STE#110;INSTALL TWO(2)100 AMP SUB PANELS(VACANT UNIT) I hereby affirm under penalty of perjury one of the following two declarations: 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 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 316 20 112 A(Tenant Improvements) 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 Cupertinoagainst 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. Signature Date 12/01/2016 Issued by: = "' Date: 12/01/2016 -► 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 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. l`,as owner of the property,am exclusively contracting with licensed Signature of Applicant: contractors to construct the project(Sec.7044,Business&Professions Code). Date:12/01/2016 I hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER 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. 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 pernut is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&Safety Code,Section 25532(a)should I store or handle hazardous 3r,7 I certify that in the performance of the work for which this permit is issued I material. Additionally,should I use equipment or devices which emit hazardous ft�l� shall not employ any person in any manner so as to become subject to the ai contaminants as defined by the Bay Area Air Quality Management District I f Vv�Worker's Compensation laws of California. It 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 ections 2 ,0 25533,and 25534. Labor Code,I must forthwith comply with such provisions or this permit shall 4 fa be deemed revoked. Owner or authorized agent c APPLICANT CERTIFICATION Date:12/01/2016 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. !moi' # GENERAL PERMIT APPLICATION E P v _ COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION �."-r.r 10300 TORRE AVENUE•CUPERTINO,CA 95014-3255 ir (408)777-3228•FAX(408)777-3333•buildinci cupertino.orq I s C CUPERTINO Z- 240/6 '3/90 ❑PLUMBING ❑MECHANICAL ❑ELECTRICAL ❑MISCELLANEOUS PROJECT ADDRESS 1 C' ,7. +'C,clia CreekAPN# OWNER NAMEM � PHO E MAII. Q6,09LA, 4661177 30i t 6 e Uc.ljca sG , ` , STREET ADDRESS ( Li-7' Ste® ,:/„CITY,STATE,47' ,p FAX 0 723 6776 �c3� CONTACT NAME ' (1` p y/ (4 _ PH C) 0�?/ f P EMAIL STREET ADDRESS I o i z-3rA,s Wo/ .n I CITTSTATEf ,ZIPtIs FAX OWNER OWWN�R-BUILDER ❑ OWNER AGENT El CONTRACTOR 0 CONTRACTOR AGENT 0 ARCHITECT 0 ENGINEER 0 DEVELOPER 0 TENANT CONTRACTOR NAME oe.#1.4 44 LICENSE NUMBER LICENSE TYPE BUS.LIC# COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC# COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE USE OF 0 SFD 'DUPLEX ❑ MULTI-FAMILY PROJECT IN W0 YES PROJECT IN 0 YES IS THE BLDG AN )esoYES BUILDING: COMRCLSL URBAN INTERFA CILDLANDE AREA _�Tj SO FLOOD ZONE EICHLER HOME? DESCRIPTION OF WORIf r� P-e c vvt, 0� Q '?.f Cwt= .12/1(lel frf p 6C- """�L ' 4 ,� c X14. (1 - s s trj lq(1Z9 5-Itect444 6,,,,,eAr., S loo 44 S,,,--(t Ito Vertu S TOTAL VALUATION: 5 00 ' 7-'77,2, By w,I certify to each of the following: I am the property owner or authorized agent to act.. h e property owner' o .a'� r z-.' By my signature Belo application and the information I have provided is correct. I have read the Description of Work and verify it is accurate. ; - o coma .' • .Ile loca ordinances and state 1 ws relating to burl...•J c..stru Iajrthorize representatives of Cupertino to enter the ab!?..v .property for inspection purposes. l Signature of Applican/Agent: '1 \-4 Date: IL SUPPLEMENTAL INFORMATION REQUIRED - OFFICEUSEONLY' i °, Li', OVER-TIlE-COIJNTER © EXP, sS,� r,• P STANDARD :-: r ,. ,r.a.'LARGE, r> i Ae � tiIAJOR MEPMiscApp_2011.doc revised 06/21/11 ; ,., \ OWNER-BUILDER DISCLOSURE ORM COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION -t;t$ 10300 TORRE AVENUE•CUPERTINO, CA 95014-32'5 • (408)777-3228•FAX(408)777-3333•buildinqecupe ino.orq CLIPERTIN Dear Propert Owner(s): An applicatio for a building permit has been submitted in your name lis ling;yourself as the builder of the property improvemen p specified at: SITE ADDRES /f APN BP# 9 yr9J�r., u- 6 Zo •2 - « -3r96 r E V fr r A s- OWNER; 5 ss^/. i 0�/!'C , care. 45,..) ! // � DESCRIPTION OF WORK: J < rT /!O /4/577°/4/577°,41--- ` ) ]MI4 /do Afe .s-V,8 We are provi ing you with an Owner-Builder Acknowledgment and Infor ation Verification Form to make you aware of your respons bilities and possible risk you may incur by having this per it issued in your name as the Owner-Builder. We will not issue a building permit until you have read, initialed your u derstanding of each provision, signed, and returned this form to us at our official address indicated. An agent .f the owner cannot execute this notice unless you, the property owner, obtain the prior approval of the permitting authority. OWNER'S ACKNOWLEDGMENT AND VERIFICATION OF INFORMA ION (DIRECTIONS:Please read and initial each statement below to signify ou understand or verify this information.) I nderstand a frequent practice of unlicensed persons is to ave the property owner obtain an"Owner- Builder" wilding permit that erroneously implies that the property o ner is providing his or her own labor and material personally. I,as an Owner-Builder, may be held liable and subject to serious financial risk for any injuries sustained by an unlicensed person and his or her employees while working on m property. My homeowner's insurance may not provideoverage for those injuries. I am willfully acting as an,Owne -Builder and am aware of the limits of my insurancecoverage for injuries to workers on my property. dI2I nderstand building permits are not required to be signed •y property owners unless they are responsible for theMR-73/ , cons ruction and are not hiring a licensed Contractor to assume his responsibility. v 3'.}I understand as an"Owner-Builder"I am the responsible pa y of record on the permit. I understand that I may protect yself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her name in-tead of my own. i . I nderstand Contractors are required by law to be licensed and bonded in California and to list their license numbers on permits and contracts. '12.I nderstand if I employ or otherwise engage any persons, o her than California licensed Contractors, and the to I v`alule of my construction is at least five hundred dollars($500), including labor and materials, I may be consider d an "employer"under state and federal law. C 6?I nderstand if I am considered an "employer"under state a d federal law, I must register with the state and federal g vernment,withhold payroll taxes, provide workers'compe sation disability insurance,and contribute to unemplo ment compensation for each "employee." I also understano my failure to abide by these laws may subject m o serious financial risk. ,7i 1 understand under California Contractors' State License La ,an Owner-Builder who builds single-family residenti I structures cannot legally build them with the intent to off_r them for sale, unless all work is performed by licensed ubcontractors and the number of structures does not exc.ed four within any calendar year, or all of the work is p- or ed under contract with a licensed general building Contrau tor. :. I derstand as an Owner-Builder if I sell the property for w ich this permit is issued, I may be held liable for any fina cial or personal injuries sustained by any subsequent own:r(s)that result from any latent construction defects in the workmanship or materials. Owne Builde7Forn7 2010.doc revised 04/14/10 I i li 'i ,'. I nderstand I may obtain more information regarding my obl gations as an "employer"from the Internal Revenue Service, the United States Small Business Administration, he California Department of Benefit Payments, and the alifornia Division of Industrial Accidents. I also understand may contact the California Contractors' State License oard (CSLB)at 1-800-321-CSLB(2752)or www.cslb.ca.gev for more information about licensed contracto s. . i1}e e?I am aware of and consent to an Owner-Builder building pe mit applied for in my name, and understand that I am� the p rty legally and financially responsible for proposed constru tion activity at the site address listed above. INV. I agree that, as the party legally and financially responsible or this proposed construction activity, I will abide by all ap licable laws and requirements that govern Owner-Builders as well as employers. 12. I agree to notify the issuer of this form immediately of any a•ditions, deletions, or changes to any of the ifiv information I have provided on this form.Licensed contractors are regulated by laws designed to protect the public. If you contrlact with someone who does not have a license, the Contra tors' State License Board may be unable to assist yogi with any financial loss you may sustain as a result of a co plaint. Your only remedy against unlicensed Contractors may be in civil court. It is also important for you to unde tand that if an unlicensed Contractor or employe of that individual or firm is injured while working on your p operty,you may be held liable for damages. If you obtaina permit as Owner-Builder and wish to hire Contractors, ou will be responsible for verifying whether or not those Cotactors are properly licensed and the status of their workers' compensation insurance coverage. CONSTRUCiON LENDING AGENCY (DIRECTION' :Please complete the following construction lending agency information.) 1 I hereby affir that there is a construction lending agency for the perfo mance of the work for which this permit is issued (Sec 3097 Ci .) Lender Nam Lender Address: Before a building permit can be issued,this form must be complet-d and signed by the property owner and returned tot e agency responsible for issuing the permit. Note:A 'opyof the property owner's driver's license, form notarize ion, or other verification acceptable to the city may be req ired to be presented when the permit is issued to verify the property owner's signatur , Property Owner's Signature: , JC3� Date;/,�1Z. )at l6 1. (NOTE: The ollowing Authorization Form is required to be completed b the property owner only when designating an agent of the •roperty owner to apply for a construction permit for the 0 er-Builder). AUTHORIZATION OF AGENT TO ACT ON P AOPERTY OWNER'S BEHALF Excluding the Notice to Property Owner,the execution of which I unders and is my personal responsibility, I hereby authorize the ollowing person(s)to act as my agent(s)to apply for, sign, and file the documents necessary to obtain an Owner-Build-r Permit for my project. Scope of Construction Project(or Description of Work): Project Location or Address: Name of Authorized Agent: Tel No Address of A thorized Agent: I declare and r penalty of perjury that I am the property owner for the address listed above and I personally filled out the above inform tion and certify its accuracy. Note:A copy of the property owner's driver's license, form notarization, or other verification a ceptable to the city may be required to be presented when the permit is issued to verify the property owner's signature. Property Ow er's Signature: Date: Qi4'ne]Builde7Fol7n 2010:doc revised 04/14/10