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B-2017-0176CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: CONTRACTOR: PERMIT NO: B-2017-0176 1113 STEEPLECHASE IN CUPERTINO, CA 95014-5816 (359 31 046) GOGO ROOTER SAN JOSE, CA 95112 OWNER'S NAME: TRAN YEN T N TRUSTEE DATE ISSUED: 01/30/2017 OWNER'S PHONE: 303-990-2633 PHONE NO: (408) 282-7025 License Class CC -36 Lie. #939034 Contractor GOGO ROOTER Date 10/31/2017 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. BUILDING PERMIT INFO: X BLDG —ELECT X PLUMB _ MECH X RESIDENTIAL _ COMMERCIAL JOB DESCRIPTION: I hereby affirm under penalty of perjury one of the following two declarations: FOUNDATION CLEANOUT 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. 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. 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 and state laws relating to building construction, and hereby authorize 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 may accrue against said . in consequence of the granting of this permit. Additionally, the applica u erstands and will comply with all non -point source re �pertino Municipal Code, Section 9.18. - Signature' Date 91/30/2017 I hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: 1. I, as owner of the property, or my employees with wages as their sole compensation, will do the work, and the structure is not intended or offered for Sq. Ft Floor Area: I Valuation: $2115.00 APN Number: Occupancy Type: 359 31 046 PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR, 180 DAYS FROM LAST CALLED INSPECTION. Issued by: Kim Dunbar RE -ROOFS: All roofs shall be inspected prior to any roofing material being installed. If a,roof is installed without first obtaining an inspection, I agree to remove all new materials 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: 01/30/2017 hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER r. 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. 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. s. I certify that in the performance of the work for which this permit is issued, I sball not employ any person in any manner so as to become subject to the Worker's Compensation laws of California. If, after making this certificate of exemption, I become subject to the Worker's Compensation provisions of the Labor Code, I must forthwith comply with such provisions or this permit shall be deemed revoked. 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 and state laws relating to building construction, and hereby authorize 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 may accrue against said City in consequence of the granting of this permit. Additionally, the applicant understands and will comply with all non -point source regulations per the Cupertino Municipal Code, Section 9.18. Signature Date 01/30/2017 HAZARDOUS MATERIALS DISCLOSURE I have read the hazardous materials requirements under Chapter 6.95 of the California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Section 25532(a) should I store or handle hazardous material. Additionally, should I use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air uality Management District I will maintain compliance wi the Cupertino icipal Code, Chapter 9.12 and the Health & S. ety ns 2#05,25533, and 25534. Owner or authorized agen . � . Date: 01/30/2017 U CONSTRUCTION IXNDING AGENCY I hereby affirm that there is a construction lending agency for the performance of work's for which this permit is issued (Sec. 3097, Civ C.) Lender's Name Lender's Address ARCHITECT'S DECLARATION understand my plans shall be used as public records. Licensed Professional GENERAL PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION MEF (`j I 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 CUPERTINO �--j (408) 777-3228 • FAX (408) 777-3333 • building(a)cuperdno.orgmisc F I PLUMB TNCi n I`aFCu e 1.n(- A T M ,- MEPMiscApp_2011.doc revised 06/21/11 (JIvESC ,LLANr;UUS PROJECT ADDRESS a/3c�FE C TAPN # r OWNER NAME PHONE STREET ADDRESS CITY, STATE, ZIP FAX CL) C?( - CONTACT NAME , / FPHOI;TEp © i STREET ADDRESS t ` i j CITY, STATE, ZIP / ® / FAX OWNER ❑ OWNER -BUILDER ❑ OWNERAGENT . ❑ CONTRACTOR ❑ CON"FRACTORAGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME LICENSE NUMBER 3 LICEN TITE ` BUS. LIC ig !p. COMPANY NAME6tc)& G � E-MAIL FAX STREET ADDRESS CITY, STAT IP PHONE c — ?--%26 ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS. LIC COMPANY NAME E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE USE OF d-SFD.'UPLEX ❑ MULTI -FAMILY PROJECT INWILDLAND ❑ YES PROTECT IN El YES IS THE BLDG AN ❑ yg5 - BUII.DA`G: ❑ C01.4NhERCLALURBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑ NO EICHLER HOME? ❑ NO I DESCRIPTION OF WORK j TOTAL VALUATION: T i 6 Q ® 32£CFaii DBY ' By Iny signature below, I certify to each of the llowing: I am the property owner or authorized agent to act 'on the property owner's behalf. I have read this application and the information I have provided s correct. I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local ordinances and stale laws rel cc struction. I authorize representatives of Cupertino to enter the above -identified property for inspection purposes. Signature of Applicant/Agent: Date: l _ 3C) " (. SUPPLEMENTAL INFORMATION REQUIRED oFFcE sE or> i © D1 EF2-THECOi73\TER- - Y-. ;0 ExT12ESS L171STAIIDARD < fl LARGE 0 TZ4JOR MEPMiscApp_2011.doc revised 06/21/11