B-2017-0041 CITY OF CUPERTINO BUILDING PE
BUILDING ADDRESS: CONTRACTOR: P RMIT NO:B-2017-0041
10631 S S FOOTHILL BLVD CUPERTINO,CA 95014-3963(342 16 087) J W ELECTRIC
RAMONA,CA 92065
OWNER'S NAME: SCR ENTERPRISES LLC D•TE ISSUED:01/06/2017
OWNER'S PHONE:650-224-6189 P ONE NO:(760)580-6269
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT I 0:
License Class C-10 Lic.#932061
Contractor J W ELECTRIC Date 04/30/2017 X BLDG X ELECT _ 'LUMB
MECH_RESIDENT 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:
HELLO WORLD CAFE INSTALL(N)40 AMP AND 20 AMP 220
I hereby affirm under penalty of perjury one of the following two declarations: CIRCUIT
m. 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.
% I have and will maintain Worker's Compensation Insurance,as provided for by
i .Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued. Sq.Ft Floor Area: V luation:$14000.00
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: 0 cupancy Type:
and state laws relating to building construction,and hereby authorize 342 16 087
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 EXPI' S WORK IS NOT STARTED
may accrue against said City in consequence of the granting of this permit. WITHIN 180 D•YS 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 FRO LAST CALLED INSPECTION.
Signature C� Date 1/6/2017 Issued by:AbbyAyende
Date:01/06/2017
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 obta'.'.g 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:1/6/2017
I hereby affirm under penalty of perjury one of the following three declarations:
ALL ROOF CO RINGS 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. HAZARD•US MATERIALS DISCLOSURE
2. I have and will maintain Worker's Compensation Insurance,as provided for by I have read the hazardou 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&Saf•ty Code,Sections 25505,25533,and 25534. I will
permit is issued. maintain compliance with,he Cupertino Municipal Code,Chapter 9.12 and the
3. I certify that in the performance of the work for which this permit is issued,I Health&Safety Code,S ction 25532(a)should I store or handle hazardous
shall not employ any person in any manner so as to become subject to the material. Additionally,sho d I use equipment or devices which emit hazardous
air contaminants as define' by the Bay Area Air Quality Management District I
Worker's Compensation laws of California. If,after making this certificate of will maintain compliance ith the Cupertino Municipal Code,Chapter 9.12 and
exemption,I become subject to the Worker's Compensation provisions of the the Health&Safi ty Code,Sections 25505,25533,and 25534.
Labor Code,I must forthwith comply with such provisions or this permit shall _
be deemed revokedOwner'or authorized age t:
APPLICANT CERTIFICATION t�-Date: 1/6/2017
I certify that I have read this application and state that the above information is CONS RUCTION LENDING AGENCY
correct.I agree to comply with all city and county ordinances and state laws I hereby affirm that there i-a construction lending agency for the performance
relating to building construction,and hereby authorize representatives of this city of work's for which this per it 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 _ i' I
Code,Section 9.18. I understand my plans sha I be used as public records.
Licensed
Signature Date 1/6/2017 Professional
\• GENERAL PERMIT APPLICATION M E P
Av: COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
.IF 10300 TORRE AVENUE•CUPERTINO,CA 95014-3255
� � (408)777-3228•FAX(408)777-3333•buildinq(7aTINO ,cupertino.orq I S
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