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B-2017-0024 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2017-0024 6057 SHADYGROVE DR CUPERTINO,CA 95014-4644(375 40 005) ROOTER HERO PLUMBING INC MISSION HILLS,CA 91346 OWNER'S NAME: SONG ALBERT DATE ISSUED:01/04/2017 OWNER'S PHONE:408-718-5252 PHONE NO:(888)929-4376 LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: License Class C-36 Lic.#973014 Contractor ROOTER HERO PLUMBING INC Date 05/31/2018 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: REPLACE SEWER MAIN 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 p performance of the work for which this permit is issued. z:'t'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:$5000.00 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 375 40 005 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 Mun'cipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION. (/ Date: /�- Date 1/4/2017 Issued by:AbbyAyende o- Date:01/04/2017 • OWNER-BUILDER DECLA TION 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:1/4/2017 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 8z Safety Code,Sections 25505,25533,and 25534. I will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the permit is issued. s. 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 material. Additionally,should I use equipment or devices which emit hazardous shall not employ any person in any manner so as to become subject to the 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 7 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:1/4/2017 I certify that I have read this application and state that the above information is CONSTRUCTION) _NDINGAGENCY 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 Date 1/4/2017 Professional 'B-z -00i4 YGENERAL PERMIT APPLICATION MEP vCOMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 4,..L12��` 10300 TORRE AVENUE•CUPERTINO,CA 95014-3255 (408)777-3228•FAX(408)777-3333•buildinq(a�cupertino.orq CUPERTINO M I S C V. .LUMBING ❑MECHANICAL ❑ELECTRICAL ❑MISCELLANEOUS PROJECT ADDRESS ®A.) AP" t0-003 OWNER NAME (.0 f A �j ) // /h g� L 6 Y l/ / 5 1-p'-�a e �,�'-®tt PHO S/ )0 7/S- r2-i-Z.E-MAIL STREET ADDRESS 3 d^� CITY STATE,ZIP FAX 5 /��uv& /J,02e4,-srN2, e?„,�,,e-- CONTACT NAME !; //® P NEei) ai,T63 E-MAIL STREET ADDRESS CITY,STATE,ZIP FAX ❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT P CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT 0 ENGINEER 0 DEVELOPER 0 TENANT CONTRACTOR NAI j LICENSE NUN BERG , LICENT T'E6 BUS.LIC# J i O COMPANY NAME CO E-MAIL] L� ,.J 'FAX _�'LJVI ii-i 67,g_I.) STREET ADDRESS // IT TATE,ZIP PHONE --� 27 ii/! L)� ....... .,,,,/, e..) A,- Li/ 22 7 -/ 0 ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC# COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE USE OF 21E4cr DUPLEX 0 MULTI-FAM7 Y PROJECT IN WILDLAND 0 YES PROJECT IN ❑YES IS THE BLDG AN 0 YES BUILDING: 0 COMMERCIAL URBAN INTERFACE AREA 0 NO FLOOD ZONE 0 NO EICHLER HOME? 0 NO DESCRIPTION OF WORK ,. :,-e a p_e.......2.___7 4? _ . ��/,� TOTAL VALUATION: ®®0 RECEIVED BY: �iv By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on the property� is behalf. I have 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 to building construction. I audio resentatives of Cupertino to enter the above-identified property'erfor inspection purposes. Signature of Applicant/Agent: �� Date: ./,Q e'-• % / 7 • SUPPLEMENTAL INF 0' ATION )D OFFICE USE ONLY w. D OVER-THE-COUNTER ❑. EXPRESS 0 STANDARD ii ❑ LARGE g. ❑ MAJOR - MEPMiscApp 2011.doc revised 06/21/11