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B-2017-0071 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2017-0071 19469 ROSEMARIE PLAPT 1 CUPERTINO,CA 95014-3451(375 01006) STREET PLUMBING AND ROOTER SAN JOSE,CA 95128 OWNER'S NAME: ROSEMARIE PROPERTY LLC DATE ISSUED:01/13/2017 I OWNER'S PHONE:408-4284600 PHONE NO:(408)496-1155 LI .N DCONTRACTOR'S DECLARATION BUILDING PERMIT INFO: License Class C36 Lic.#582217 Contractor STREET PLUMBING AND ROOTER Date 12/31/2017 X BLDG ELECT X PLUMB I hereby affirm that I am licensed under the provisions of Chapter 9(commencing —NIECH 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 DESCRIPTION: REPLACE 75 GAL WATER HEATER,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 Compensation,as provided for by Section 3700 of the Labor Code,for the qlk!erformance of the work for which this permit is issued. 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:$1850.00 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 01 006 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 regulationsper the Cupertino Municipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION. Signature/,� Date 01/13/2017 Issued by:MELISSA I` Date:01/13/2017 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 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 ofApplicant: contractors to construct the project(Sec.7044,Business&Professions Code). Date:01/13/2017 I hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF 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. HAZARDOUS MATERIALS DISCLOSURE z. 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 3. 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.Additionally,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 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,Seo 25505,2 ,and 25534. Labor Code,I must forthwith comply with such provisions or this permit shall be deemed revoked. Owner or authorized agent: i APPLICANT CERTIFICATION Date:01/13/2017 777 /7 Ll 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 i Code,Section 9.18. 1 understand my plans shall be used as public records. Licensed Signature Date 01/13/2017 Professional I i i GENERAL PERMIT APPLICATION E P ' COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 14300TORRE°AVENUE'•CUPERTINO,CA 95014-3255 . (408)777-3228.FAX(408)777-3333•buildinaCa?cul�ertino.orc� MISC CUPERTING leg- Zat) - 0p 3—/ ❑PLU-MBWG 0WCHA1,9CAL ❑ELECTRICAL WSCELLANEOUS PROJECT ADDRESS -#IP AN# ®�-3�Q� 0l )0-6 �6p / �� � i - I7 ONVNExNAn F-r�au STREET ADDRESS QTY,STA edwrAMi J� ®/ FAX" CONTACT NAME A . wrrT .PHO f 100 ft-11S^ STREET ADDRESS A L�f�y 3 `R^►M/� (� / JS6 ❑OWNM ©0WI-M-BU DER ©OWM RAGM-T CoNmACTOR ❑C0N-MACTORAGE+,'T D ARCIZIMCT_ ❑ENaKEEP, 0 DEVELOPER ❑TEtia.3T CONTRACTORNAME ' 7 CENSET"' aI StSZ" .2w 5� (JV COIvIPA�7Y?:4NIE f � E_ MI-S{"�C d 1 ►v 4 j® F , * 4q6-CUE- STREET ADDRESS _ZIP, sr CA 'qs grna j{og /16- //SS ARCHIT£CTIENMTER NAME LICENSE NUMBER 33US.TIC= COIvIpA1QY�4jyIE EMAIL FAX I STREET ADDRESS' CITY,STATE,ZIP PHONE MIST;-OF SFD or Duplex ❑ Multi Family PROJECT W WU.DT M%M PROJECT LII STRUCTURE: ❑ Commercial URBAN TNT&RFACE AREA ❑ Yes ❑ NO FLOOD ZONE ❑ YeS ❑ NO DESCRIPTTGN GF vVORI: TOTALVALUATIC4N: ,F5b I , By my siatre ,I certify to each of the following: I am the property owner orauthorized agent to act on the property owner's behalf I have read this application and t-below information I have v" ed is coned�Ibaveread the Description ofWork and verify it is accurate. I agree to comply with all applicablelocal ordinances and Mate lain relating to b construe' rizerepres eseCupertino to enter the ab ove-fdentifod property for inspection proposes Signature of ApphicandAgent: .�. / Date: TFORMAQ :. "" nra g>a TION RE UIREI3 vti' t=rHEotzx : may` t v=�:s �bOEM- @6N �-<,s?- -Er = - 1f1EP1V1tscffpp 2011.doc revised 03115111 I _