B-2016-3257 CITY OF CUPERTINO BUILDING P RMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2016-3257
10846 LINDA VISTA DR CUPERTINO,CA 95014-4749(356 14 049) CROWN PLUMBIN
SAN JOSE,CA 9512.
OWNER'S NAME: SACHS AVI I AND GILLER-SACHS ANAT TRUSTEE DATE ISSUED:12/12/2016
•
OWNER'S PHONE:408-219-8175 PHONE NO:(408)210-9500
T,ICFNSED CONTRACTOR'S DECLARATION BUILDING PE' ii T INFO:
License Class C36 Lie.#855792
Contractor CROWN PLUMBING Date 03/31/2017 X BLDG _ELE t T X PLUMB
—MECH X RES II ENTIAL—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 DESCRIPTI 1 N:
REPLACE BUILD i G DRAIN;REPLACE SANITARY SEWER
I hereby affirm under penalty of perjury one of the following two declarations: (TRENCHLESS); " PLACE PROPERTY LINE CLEANOUT
i. I have and will maintain a certificate of consent to self-insure for Worker's
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Compensation,as provided for by Section 3700 of the Labor Code,for the �
i•• y t;]
/performance of the work for which this permit is issued. 4
11j _L .i I have and will maintain Worker's Compensation Insurance,as provided for by • \- 3 (
T Section 3700 of the Labor Code,for the performance of the work for which this c, �u _-• t
permit is issued. Sq.Ft Floor Area: Valuation:$12500.00
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 35614 049
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 E 'IBES IF WORK IS NOT STARTED
may accrue against said City in consequence of the granting of this permit. WITHIN 1 O DAYS OF PERMIT ISSUANCE OR
Additionally,the applicant understands and will comply with all non-point
source regulations er the Cupertino Municipal Code,Section 9.18. 180 DAYS FI' OM L CALLED INSPECTION.
Signature-/ �.. Date 12/12/2016 Issued by:ME Y��[
Date:12/12/2016
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 in i.ected 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 Applican:
contractors to construct the project(Sec.7044,Business&Professions Code). Date:12/12/2016
I hereby affirm under penalty of perjury one of the following three declarations: ALL ROO 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. • H• ARDOUS MATERIALS DISCLOSURE
2. I have and will maintain Worker's Compensation Insurance,as provided for by I have read the ha ardous materials requirements under Chapter 6.95 of the -
Section 3700 of the Labor Code,for the performance of the work for which this California Healt, &Safety Code,Sections 25505,25533,and 25534. I will
permit is issued. maintain complianc•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 I ode,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. Addition: y,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 comp ance with the Cupertino Municipal Code,Chapter 9.12 and
exemption,I become subject to the Worker's Compensation provisions of the the Healt i &Safety Code,jections 25505,25533,and 25534.
Labor Code,I must forthwith comply with such provisions or this permit shall
be deemed revoked. Owner or authoriz d agent:.
APPLICANT CERTIFICATION Date:12/12/2016 {
I certify that I have read this application and state that the above information is a Yt Y s ►i��►
correct.I agree to comply with all city and county ordinances and state laws I hereby affirm that here is a construction lending agency for the performance
relating to building construction,and hereby authorize representatives of this city of work's for which t is 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 pla s shall be used as public records.
Licensed
Signature Date 12/12/2016 Professional
GENERAL PERMIT APPLICATION M E P
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DI ISION
5
,.trg ; 10300 TORRE AVENUE•CUPERTINO,CA 95014-3255
(408)777-3228•FAX(408)777-3333•buildin l cupertino.orq I S C
CUPERTINO
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DPLUMBING ❑MECHANICAL ❑ELECTRICAL ❑MISCELLANEOUS
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CONTACT NAME6
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❑OWNER 0 OWNER-BUILDER 0 OWNER AGENT Yi CONTRACTOR 0 CONTRACTOR AGENT 0 CHITECT 0 ENGINEER 0 DEVELOPER 0 TENANT
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CONTRACTOR NAME ��utf G ..cc , ,LICENSE NUMBER D -) IIC: SE TYPE , BUS.LIC# zz I
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COMPANY NAME
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ARCHITECT/ENGINEER NAME LICENSE NUMBER C` BUS.LIC C
COMPANY NAME E-MAIL I FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF ❑.SFD or DUPLEX ❑ 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 ZO 0 NO EICHLER HOME? ❑NO
DESCRIPTION OF WORK ' d
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By my signature below,I certify to each o the f. owing: I am the property owner or authorized agent to act o i -� ' behalf" I have read this
application and the information I have provided is correct. I have read the Description of Work and ve ccurate. I agree to comp th all applicable local
ordinances and state laws relating to building onstruction. I authorize representatives of Cupertino to enter the above-identified property for ins : 'on purposes,
Signature of Applicant/Agent: Date: +
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SUPPLEMENTAL INFORMATION REQUIREDh -
OFFICE USE ONLY
II ' QVER THE COUNTER
Ii F. 9 EXPRESS
,. r'7 q, TANDARD `;
LARGE
a MAJOR
MEPMiscApp_2011:doc revised 06/21/11