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B-2016-3313 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS:` CONTRACTOR: PERMIT NO:B-2016-3313 10801 W ESTATES DR CUPERTINO,CA 95014-4537(369 23 033) R G S ENTERPRISES INC SAN JOSE,CA 95125 OWNER'S NAME: PICKETT CHARLES E AND SARAL TRUSTEE DATE ISSUED:12/21/2016 OWNER'S PHONE:408-981-4812 PHONE NO:(408)234-1822 LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: License Class a Lic.#711732 Contractor R G S ENTERPRISES INC Date 06/31/2018 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 DESCRIPTIOi: UPGRADE PANEL 1200 AMP);SAME LOCATION 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 C_mpensation,as provided for by Section 3700 of the Labor Code,for the i performance of the work for which this permit is issued. z! 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:$3500.00 q 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 369 23 033 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 egulations per the Cupertino Municipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION. Signature Date 12/21/2016 Issued by:AbbyAyeride Date: 12/21/2016 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. 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:12/21/2016 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 i 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.Additionall*,should I use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Mr Quality Management District I Worker's Compensation laws of California. If,after making this certificate of will maintain complia ce 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 '"" ''� APPLICANT CERTIFICATION Date:12/21/2016 I certify that I have read this application and state that the above information is CQNSTRU LENDING AGENCY correct.I agree to comply with all city and county ordinances and state laws I hereby affirm that th re is a construction lending agency for the performance relating to building construction,and hereby authorize representatives of this city of work's for which thi 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 piano shall be used as public records. SiSignature Date 12/21/2016 Licensed 9 Professional 1 WiolGo, ''' Si,3 I(4GENERAL PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION M E P ,_ 4-t.rs. 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 4is 4' CUR1N (408)777-3228•FAX(408)777-3333•buildinq(a�cupertino.orq I M I S C El PLUMBING ❑MECHANICAL El ELECTRICAL ❑MISCELLANEOUS PROJECT ADDRESS 2 f.,,1 f V R ES4 bt-i APN# -NA 2.:5_, 0$3 OWNE04,4ei ! e,�.‘i �/ N1 /c1.e-0 Z—r r kmAr—i i�u1C~C L• 4.P4. STREET ADDRESS CI , TATE,ZIP /�4 g�J, PI FAX P J(��✓ I G� �j t /�/ CONTACT NAMEf�I /�� PW %VZ 2- C .t dril S&4 O4i 4l • STREET ADDS y�fyje 0 j „If is _ „�/4f'�+�,y^," CITY,STA ,'4 er, /'^,cjc/`c FAX ❑OWNER �►❑ OWNER-BUILDER ❑ OWNER AGENT YI CONTRACTOR ❑CONTRACTORAAGENT 0 sARCHITECT ,❑+ENGINEER ❑ DEVELOPER ❑ TENANT CONT�� s es t.+ LICENSE NUMBED 7J/w 3 Z ie LICENSE TYPE BUS.LIC f�G/ !/ COMPANY NAME r 4r( 4'/��/..•�- E5At 6 e#23-ei"+�l.F7n✓i7 l/14e �v STREET A� /�v 144"411‘r, 1414-* CITY,S. )Zi �I ..s..7 'p✓ [ „, ARCHITEc G EER v L 6 (, • LICENSE NUMBER/'-, / 7 BUS.LIC# COMPANY NAME E-MAIL FAX ST TGa ,f���.�/ �,® y 1.� CITY, I PHONE ���o�• � �1V'�„��� Wei i..�s tz—. �� USE OF FD or DUPLEX 0 MULTI-FAMILY 'PROJECT IN WILDLAND 0 YES PROJECT IN ❑YES IS THE BLDG AN 0 YES BUILDING: ❑COMMERCIAL �j URBAN INTERFACE,AAREA ❑ NO FLOOD ZONE ❑NO { EICHLER HOME? 0 NO DESCRIPTION OF WORK 7al , j e L_St e / 7- /!,J/��}__ , t ZOO /?VlA 5 c 6 J�7`7 +�,i 4"l , • TOTAL VALUATION: 4 27 V RECEIVED IIY: 1,f 'i1>Ill!`"" By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on the property owner's be.alf. I have read this application and the information I have provided is correct. I have read the Description of Work and verify it is acburate. I agree to comply with all applicable local ordinances and state laws relatin• • •.'•' _cons 1 ction. I authorize representatives of Cupertino to enter the a love-identified property for inspection purposes. Signature of Applicant/Agent: t—.• Date: i. Q.+Z '/# 7CP Lao' SUPPI'NTAL INFORMATION REQUIRED OFFICE USE ONLY w. 0 OVER-THE-COUNTER . ❑ EXPRESS U © STANDARD 0 'LARGE F., ED MAJOR MEPMiscApp_2011.doc revised 06/21/11