B-2017-0105 CITY OF CUPERTINO BUILDING PERMIT
BUILDINGADDRESS: CONTRACTOR: PERMIT NO:13-2017-0105
1105 SCOTLAND DR CUPERTINO,CA 95014-5050(362 26 037) CUPERTINO
PLUMBING INC
SAN JOSE,CA 95124
OWNER'S NAME: MONTANEZ JOSEPH J DATE ISSUED:01/19/2017
OWNER'S PHONE:408-401-6085 PHONE NO:(408)253-0618
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class B:C-36 Lic.#624905
Contractor CUPERTINO PLUMBING INC Date 04/30/2018 X_BLDG —ELECT X 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 DESCRIPTION:
I hereby affirm under penalty of perjury one of the following two declarations: REPLACE SEWER MAIN;CLEAN OUT
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.
ve and will maintain Worker's Compensation Insurance,as provided for by
S ction 3700 of the Labor Code,for the performance of the work for which this
ermit is issued. Sq.Ft Floor Area: Valuation:$2000.00
APPLICANT CERTIFICATION
certify that I have read this application and state that the above
information is correct.1 agree to comply with all city and county ordinances APN Number: Occupancy Type:
and state laws relating to building construction,and hereby authorize 362 26 037
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 Municipal Code,Section 9.18. TSO DAYS FROM LAST CALLED INSPECTION.
Signature —/�,-!9 �_ Date 1/19/2017 Issued by:AbbyAyende
Date:01/19/2017
OWNER-BUILDER D RATION
I hereby affirm that I am exempt from the Contractor's License Law for one of the RE-ROOFS-
following
F 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:1/19/2017
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
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
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
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,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 CERTIFICATION Date:1/19/2017
I certify that 1 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
Code,Section 9.18. 1 understand my plans shall be used as public records.
Licensed
Signature Date 1/19/2017 Professional
GENERAL PERMIT APPLICATION E P
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255
CEJ4'ERi"lNC3 (408)777-3228•FAX(408)777-3333•buiidinaCc�cupertino ora misc
PLUMBING [:1 MECHANICAL []ELECTRICAL ❑MISCELLANEOUS
PROJECT ADDRESS S_ scol APN# � _2 `, �
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OWNER NAME J Q PHONE � L -MAIL
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STREET ADDRESS, .5__ 15C
CITY,STATE,ZIP 6 FAX
CONTACT NAME PHONE E-MAIL
STREET ADDRESS CITY,STATE,ZIP FAX
❑ OWNER ❑ OWNER-BUILDER ❑ OWNERAGENT. ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME , LICENSE NUI LIC E TYPE BUS.LIC# '�
C, 6 2G..
COMPANY NAME E-MAIL ` •-- FAX
20
STREET ADDRESS CITY,STATE,ZIP PHONE
l �J 66oi-7'I �I/C QJ5 5 C $'lam
ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC#
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF UrSFD or DUPLEX ❑ MULTI-F.AMI.Y PROJECT IN W.IL.DLAND ❑ YES PROJECT IN ❑YES IS THE BLDG AN ❑YES
BUILDING: ❑COMMERCIAL URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑NO EICHLERHOME? ❑NO
DESCRIPTION OF WORK4-
AO)"We r //�? (�. C®/ea". -7 r'�3 f2d _
TOTAL VALUATION: 6? RECEIVED BY: 11
�
By my signature below,I 6ertify to each of the following: I am the property owner or authorized agent to act on the property ow-er's behalf. I have read this
application and the infonnation 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 lawsrelating to b 'ding construction. I authorize representatives of Cupertino to enter the above-identified/property for inspection purposes.
Signature of Applicant/Agent: .s Date:
SUPPLEMENTAL INFORMATION REQUIRED
OFFICE USE oI\*LY
.. "it .OVER THE-COUNTER
EXPRESS
U:
. STArDARD
D LARGE
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MEPMiscApp_2011.doe revised 06121111