B-2017-0267CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS:
CONTRACTOR:
PERMIT NOO-2017-0267
20610 KIRWIN IN CUPERTINO, CA 9501414303 (359 23 038)
JONATHAN WEI CHIH
SU
CUPERTINO, CA 95014
OWNER'S NAME: SU PHILIP AND CHEN MICHELLE MEI LIEN
DATE ISSUED: 02/1.5/2017
OWNER'S PHONE- 510-585-8808
PHONE NO: (448) 255-8999
LICENSED CONTRACTOR'S DECLARATION
BUILDING PERMIT INFO:
License Class a Lic. #621833
Contractor JONATHAN WEI CHIN SU Date 12/3112017
X BLDG X ELECT _PLUMB
MIECH X RESIDENTIAL COMMERCIAL
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.
JOB DESCRIPTION:
INSTALL TEMP POWER POLE 100 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
performance of the work for which this permit is issued.
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
Sq. Ft Floor Area:
Valuation: $500.00
i
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
APN Number:
Occupancy 1)7
e*
35923038
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
PERMIT EXPIRES IF WORK IS NOT STARTED
may accrue against said City in consequence of the granting of this permit.
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WITHIN 180 DAYS OF PERMIT ISSUANCE OR
Additionally, the applicant understands and will comply With all non -point
Code, Section 9.18.
I
180 DAYS FROM LAST CALLED INSPECTION.
source regulations per Cupertino Municipal
Signatul Date 0 /15/2017
Issued by: MELIS
V
Date: 02_/15/2017
OWNER -BUILDER
I hereby affirm that I am exempt from the Contractor's License Law for one of the
RFcROOFS:
.
All roofs shall be inspected prior to any roofing material being installed. If a roof is
following two reasons:
installed without first obtaining an inspection, I agree to remove all new materials for
1. 1, as owner of the property, or my employees with wages as their sole
inspection.
compensation, will do the work, and the structure is not intended or offered for
sale (Sec,7044, Business & Professions Code)
2. 1, as owner of the property, am exclusively contracting with licensed
Signature ofApplicant: —
contractors to construct the project (Sec.7044, Business & Professions Code).
Date: 02/15/2017
I hereby affirm under penalty of perjury one of the following three declarations*
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
1. 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.
2. 1 have and will maintain Worker's Compensation insurance, as provided for by
HAZARDOUS MATERIALS DISCLOSURE
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
maintain compliance with the CupertinolMunicipal Code, Chapter 9.12 and the
permit is issued.
Health & Safety Code, Section 25532(a) should I store or handle hazardous
3. 1 certify that in the performance of the work for which this permit is issued, I
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material. Additionally, should I use equipment 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 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 agent:
APPLCERTIFICATION
Date: 02/15/2017ICANI CONST TION LENDIN. AGEN CY
I certify that I have read this application and state that the above information is
I hereby affirm that there is a construction lending agency for the performance
correct. I agree to comply with all city and county ordinances and state laws
of work's for which this permit is issued (Sec. 3097, Civ C.)
relating to building construction, and hereby authorize representatives of this city
Lender's Name
to enter upon the above mentioned property for inspection purposes. (We) agree
to save indemnify and keep harmless the City of Cupertino against liabilities,
Lender's Address
judgments, costs, and expenses which may accrue against said City in
consequence of the granting of this permit. Additionally, the applicant understands
ARCHITECT' DE
and will comply with all non -point source regulations per the Cupertino Municipal
I understand my plans shall be used as public records.
Code, Section 9.18.
Licensed
Signature Date 02/15120.17
Professional
GENERAL PERMIT APPLICATION
MEP
COMMUNITY DEVELOPMENT DEPARTMENT - BUILDING DIVISION
AFW&
10300 TORRE AVENUE - CUPERTINO, CA 95014-3255 Isu
(408) 777-3228 - FAX (408) 777-3333 • buiIdina6bcui)erHno.orq
CUPERTINO
MECH-ANICAL ELECTRICAL DMISCELANEOUS
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PROJECT -ADDRESS APNI 9 '3 5 '3 -40
OWNER NAME PHONEE-MAIL
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STREET ADDRESSFAX
CONTACT NAME Ga E-MAIL
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CONTRACTOR NA -ME LICENSE MIMBER LICENSEWPE
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COMPANY NAME
STREET ADDRESS
CITY, STATE, ZIP
PHONE
ARCHITECTIENGINEERNA-ME LICENSE NUMBER
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COMPANY NAME
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FAX
STREET ADDRESS
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USE OF V3F.3-o—D'LTPLEX ❑ MULTI -FAMILY PROTECT N7 WILDLAND ❑ YES 4jPROTECT N ❑ YES
IS THE BLDG AN, ❑ YES
BUILDING: Fl COMgIERCIAL I URBAN INTERFACE AREA NO I FLOOD ZONE �NO
LLL
EICHLERHOME? NO
DESCRIPTION OF WORK
(00 A-mip
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 owner's behalf. I have read this
application and the information I have provided is correct. I have read the Description ofWork and verify it is accurate. I agree to comply with all applicable local
I
ordinances and state lawsyclatingto building construction. I authorize representatives of Cupertino to enter the above-identifiedproperty for inspection purposes.
Date:
Signature ofApplicant/Agent: 17
SUPPLENtEONTAL INFORMATION REQUIRED
E
AUNT -E
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Ad-EPAIIiscApp 411.doc revised 06121111