B-2017-0227CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS:
CONTRACTOR:
PERMIT NO:
B-2017-0227
19419 STEVENS CREEK BLVD STE 150 CUPERTINO, CA 95014 (316 20 112)
BOAZ RENOVATIONS
INC
SAN JOSE, CA 95117
OWNER'S NAME: MAIN STREET CUPERTINO
DATE ISSUED:
02/07/2017
OWNER'S PHONE: 408-777-3081
PHONE NO: (4'
8) 279-0300
LICENSED CONTRACTOR'S DECLARATION ATION
BUILDING PERMIT INFO:
License Class ELECTRICAL Lic. #943011 M Ck0
Contractor BOAZ RENOVATIONS INC Date 03/31/2017
X BLDG X ELECT _ PLUMB
I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing
MECH _ RESIDENTIAL X CO
RCIAL
with Section 7000) of Division 3 of the Business & Professions Code and that my
license is in full force and effect.
JOB DESCRIPTION:
SUITE 150 - (1) PANEL (200 AMP)
I hereby affirm under penalty of perjury one of the following two declarations:
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
�wcrformanceof 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: $5100.00
APPLICANT ANT RTIFICATION
I certify that I have read this application and state that the above
APN Number:
Occupancy Type:
information is correct. I agree to comply with all city and county ordinances
and state laws relating to building construction, and hereby authorize
316 20 112
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
ORK IS NOT STARTED
may accrue against said City in consequence of the granting of this permit.
Additionally, the applicant understands d ill comply with all non -point
WITHIN 180 DAYS OF
PERMIT ISSUANCE OR
source regulations per the Cuperting i al Code, Section 9.18.
180 DAYS FROM LAST
CALLED INSPECTION.
Signature Date 2/712016
Issued by: Abby Avende
OWNER -BUILDER DECLARATION
Date: 02/07/2017
f
I hereby affirm that I am exempt from the Contractor's License Law for one of theRE-ROOFS:
following two reasons:
All roofs shall be inspected prior to any rPofmg
material being installed. If a roof is
t. I, as owner of the property, or my employees with wages as their sole
installed without first obtaining an inspection,
inspection.
I agree to remove all new materials for
compensation, will do the work, and the structure is not intended or offered for
sale (Sec.7044, Business & Professions Code)
z. I, as owner of the property, am exclusively contracting with licensed
Signature ofApplicant:
contractors to construct the project (Sec.7044, Business & Professions Code).
Date: 2/7/2016
I hereby affirm under penalty of perjury one of the following three declarations:
i. I have and will maintain a Certificate of Consent to self -insure for Worker's
ALL ROOF COVERINGS TO,
BE CLASS "A" OR BETTER
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. 1 will
permit is issued.
maintain compliance with the Cuperting 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 stare or handle hazardous
material. Additionally, should I use equhp 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 Areaa Air Quality Ma ment District I
A
Worker's Compensation laws of California. If after making this certificate of
will maintain compliance with the Cupertino Municipal C9 e, hapter 9.12 and
exemption, I become subject to the Worker's Compensation provisions of the
the Health & Safety Code, Sections 25505, 25 d 5534.
Labor Code, I must forthwith comply with such provisions or this permit shall
be deemed revoked. =-
Owner or authorized t:
APPLICANT CERTIFICATION
Date: 2/7/2016
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 construct on lending agency for the performance
relating to building construction, and hereby authorize representatives of this city
of work's for which this permit is issue (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
Code, Section 9.18.
ARCHITECT'S E I
1 understand my plans shall be used as public records.
Signature Date 2/7/2016
Licensed
Professional
CUPERTINO
�- ),C) I
GENERAL PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228 • FAX (408) 777-3333 • buildino(�cupertino.org
n PLTJI QBING n 114ECHANICAT
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PROJECT ADDRESS 19419
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USE OF .,DiPLEX ❑ MULTI -FAMILY I PROJECT IN WJI..DLAND [] YES
BUILDIN' G: V?COAfUgRCLIJ, I URBAN IN'TERFACEAREA ❑ NO
PROJECT IN ❑YES
FLOOD ZONE ❑ NO ..
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IS THE BLDG AN ❑ YES
EICHLERHOME? ❑ NO
DESCRIPTION OF WOPK
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TOTAL VALUATION:; '. _ ,... ,...,
By my signature below, I certify to each of the following: I am the property owner or authorized agent to act on the property own 's beh lf. I have read this
application and the information I have provided is correct. I ha Te rea4 the Description of Work and verify it is accurate. I agree Io comply with all applicable local
ordinances and state laws relating to building construction. " of representatives of Cupertino to enter the above -identified jproperty for inspection purposes.
Signature of Applicant/Agent: Date: � / % / l I7
SU7PLEMENTAL INTPORMATION REQUIRED
OTFICE
' ST411BARD.:.._
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