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B-2017-0259CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: CONTRACTOR: PERMIT NO: B-2017-0259 10050 N WOLFE RD CUPERTINO, CA 95014-2521 (316 20 086) T CARROLL F S ELECTRICAL HAYWARD, CA 94544 OWNER'S NAME: I&G DIRECT REAL ESTATE 27 LP DATE ISSUED: 02/14/2017 OWNER'S PHONE: 510-366-1767 PHONE NO: (510) 537-4400 LICENSED CONTRACTOR'S DECLARATIOX BUILDING PERMIT INFO: License Class C110 Lic. #829543 Contractor T CARROLL F S ELECTRICAL Date 12131/2017 X BLDG X ELECT _ PLUMB I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing MECH RESIDENTLAL X COMMERCIAL with Section 7000) of Division 3 of the Business & Professions Code and that my license is in full force and effect. JOB DESCRIPTION: INSTALL DEDICATED CIRCUIT FOR ILLUMINATED WALL SIGN I hereby affirm under penalty of perjury one of the following two declarations: (SUGARCRM - SIGN PERMIT B-2017-0082) 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. 2. J //ave and will maintain Worker's Compensation Insurance, as provided for by j Section 3700 of the Labor Code, for the performance of the work for which this Sq. Ft Floor Area: Valuation: $1800.00 permit is issued. APPLICANT CERTIFICATION 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 20 086 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. Additionally, the applicant understar(ds and will'comply with all non -point WITHIN 180 DAYS OF PERMIT ISSUANCE OR source regulations per the Cupp, rt no Muni l ode, Section 9.18. 180 DAYS FROM LA ED INSPECTION. ,ti-^ Signature Date 02/14/2017 Issued by: M I AN OWMM,-BJ tT DER DECLARATION Date: 02/14/2017 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 of Applicant: contractors to construct the project (Scc.7044, Business & Professions Code). Date: 02/14/2017 I hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER r. 1 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 3. 1 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! -C e, Chapter 9.12 and exemption, I become subject to the Worker's Compensation provisions of the the Health & Safety Code, Sectionyf5505, 253 , and 25534. Labor Code, I must forthwith comply with such provisions or this permit shall be deemed revoked. Owner or authorized agent: APPLICANT CERTIFICATION Date: 02/14/2017 ` I certify that I have read this application and state that the above information is C STRYXTION 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 SiSignature Date 02/14/2017 9 Professional GENERAL PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION m P 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 CUPERTtTiit3 (408) 777-3228 • FAX (408) 777-3333 • buildingQcupertino.org m I , ❑PLTJNIBING I—I1,1ECHANIC4L �.TF.C'TRMAT. 7TRTCr1TTAXTrZnT1c PROJECT ADDRESS ,CPN 4 OV nERNAME� f� / D ` PHONE `` / � E-MAIL t Z— 10 31C�� L STREET ADDRESS �j CITY, STATE, ZIPS / _ 2OC%� 1:5510,UGc�G/£" /.elf ?..55' g'S(0� FAX CONTACT NAME PHONE51d:.37 „YOJ E 1vIAIL �� / 5����44'e- Aw STREET ADDRESS CITY, STATE, ZIP f' � FAX � ❑ OWNER ❑ OWNER -BUILDER ❑ OWNTTERAGEATT CON7?-ACTOR ❑ CO?\TRACTORAGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENA',T CONTRACTOR N AME7 l7 I �S LICENSE NUMBER � � � LICENSE TITEC1 0 BUS. LIC ; � (0 COMPANY NAME —y— / E-NLAII 7-efl F,S "Bed 163�, FAX r STREET ADDRESS Z !J t 2 ( lvz Si CITY, STATE, ZIP// dh21 ,� 6 ARCHITECT/ENGINEER.NAME I LICENSE NUMBER —11 BUS, LIC COMPANY TAME E-MAFL FAX �— STREET ADDRESS CITY, STATE, ZIP PHONE USE OF ❑ SFD OCDLYLEX ❑ MULTI-F.Ahffi.Y I PROJECT IN WILDLAt\TD ❑ YES PROSECT IN ❑ YES IS THF, BLDG ATT El -,,Es BTJILDAG: grCONMERCLAL I URBAN INTERFACE AREA ❑. NO FLOOD ZONE ❑ NO .. + EICHLERHOmE? ❑ NO DESCRIPTION OF WORK 4T�D l�® �� �ff�tc�r1_5��.��tC i f L_ r 4a A-( 17 -1 -fu r- L I�2 /3 Z 0- !r2, 1 TOTAL VALUATION: f�GJ �}� RECEI� G By my signature below, I certify to each of the following: I am the property owner or authonzed anent to act on the property er's be I have rea application and the infonnation I have provide is COITeCy I have read the Description of Work and verify it is accurate. gre mply with all applicable local ordinances and state laws relating to b onstru o uthoiize representatives of Cupertino to enter the above -i nor e�property for inspection purposes. Signature of Applicant/Agent: Date: 2 `! ! �� `� SUPPLEMENTAL INFORMATION REQUIRED <-;_. :..::::. .:...::.:::.:..::..:.,;:.:_::.. <>...:::::•.:..:.. y © E�T32ESS- U , ❑ STA 'D ARD . .. v- MEPAlfiscApp_2011.doe revised 06/21/11