B-2017-0307CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO: B-2017-0307
7482 SHADOWHILL LN CUPERTINO, CA 95014-5052 30 097)
(362 DALCON
SAN JOSE, CA 95110
OWNER'S NAME: QUALLS RALPH A JR AND LUCAS KATHRYN A TRUST
DATE ISSUED: 02/24/2017
OWNER'S PHONE: 408-775-5029
PHONE NO: (408) 278-1809
BUILDING PERMIT INFO:
LICENSED NSD ONTR TOR'c D ORATION
License Class = Lic. #582916
Contractor DALCON Date 12/31/2017
X_ BLDG X ELECT — 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 100 AMP MAIN PANEL WITH 200 AMP
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. I have and will maintain Worker's Compensation Insurance, as provided for by
v� Section 3700 of the Labor Code, for the performance of the work for which this
permit is issued.
Sq. Ft Floor Area:
Valuation: $2000.00
AULICANT CER11FICATION
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
362 30 097
representatives of this city to enter upon the above mentioned property for
inspection purposes. (We) agree to sve indemnify and keep harmless the
City of Cupertino against liabilities, ju ments, costs, and expenses which
PERMIT EXPIRES IF WORK IS NOT STARTED
may accrue against said City in con uence of the granting of this permit.
Additionally, the appli nt understa d and will comply with all non -point
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
source regulations a the Cupertin unic' I Code, Section 9.18.
180 D SPECTION.
f.
Signature --V ate 02/24/2017
Issued by: M LI AN
f
Date: 02/24/2017
OWNER -BUILDER DECLARATIf1N
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 ofApplicant:
contractors to construct the project (Sec.7044, Business & Professions Code).
Date: 02/24/2017
I hereby affirm under penalty of perjury one of the following three declarations:
1. I have and will maintain a Certificate of Consent to self -insure for Worker's
ALL ROOF COVERINGS TOBE 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. 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(x) should I store or handle hazardous
shall not employ any person in any manner so as to become subject to the
which emit hazardous
material. Additionally, should I use equqAirQuali
Worker's Compensation laws of California. If, after making this certificate of
air contaminants as defined by the Bay Management District I
exemption, I become subject to the Worker's Compensation provisions of the
h,� maintain compliance with the Cuode apter 9.12 and
the Health & Safety Code e 3 25534.
Labor Code, I must forthwith comply with such provisions or this permit shall
be deemed revoked.
Owner or authorized agent %
APPLICANT CERTIFICATION
Date: 02/24/2017
certify that I have read this application and state that the above information is
CONSTRUCTION LFNDING 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.
Signature Date 02/24/2017
Licensed
Professional
GENERAL PERMIT APPLICATION P
rk COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION ME
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
UPERTINO (408) 777-3228 • FAX (408) 777-3333 • building(a)-cupertino.org S C
n PLUMBTNG n I`aFru A NTIC' e T 1—1 - __ _
IVIISCE
PROJECT ADDRESS
LLAMEOUS
APN #
OWNER NAME
PHO q(n
E-MAIL
STREET ADDRESS �-'] y i i CITY, STATE, ZIP R
SCTI ` v
FAX
CONTACT NAME
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STREET ADDRESS
CITY, STATE, ZIP
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❑ OWNER ❑ OWNER -BUILDER ❑ OWNERAGENT R CONTRACTOR ❑ CONTRACTORAGENI' ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENAPIT
CONTRACTOR NA` n P C
\ C E/ l
LICENSE NUMB
LICENSE TYP�
BUS. LIC # S-1COMPANY
NAME
E_ IL •
FAX
STREET ADDRESSc
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C Y, STATE, ZIP
A
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ARCHITECT/ENGINEER
ARCHITECT(ENGINEER NAME
LICENSE NUMBER
BUS. LIC #
COMPANY NAME
E-MAIL
FAX Y
STREET ADDRESS
CITY, STATE, ZIP
PHONE
USE OF ❑ SET) or DUPLEX ❑ MULTI -FAMILY
BUILDING: ❑ COMMERCIAL
PROJECT IN WILDLAND ❑ YES
URBAN INTERFACE AREA ❑ NO
PROJECT IN ❑ YES
FLOOD ZONE ❑ NO -
IS THE BLDG AN S
EICHLER HOME? ❑ NO
DESCRIPTION OF WORK \ V O
C� a
TOTAL VALUATION: 0
RECEIVED BY
By my signature below, I certify to each of the following: I e propegy owner or authorized agent to act on the property ow s behalf. I have read '
application and the infonnation I have pro i is corre e"rea e Desc 'ption of Work and verify it is accurate. I a to co m 1 pplicable local
ordinances and state laws relating to b ' in construction. I th e representatives of Cupertino to 'enter the above-identi pro rty for p/ec`t"ioon purposes.
Signature of Applicant/Agent: Date: !,� �— / t
SUPPLEMENTAL INF TION REQUIRED
OFFTCE USE ONLY
❑ OVER TILE -COUNTER
n,
❑ EXPRESS
❑ STANDARD
u
❑ LARGE
El MAJOR
MF.PMiscAp�_2011.doc revised 06/21/11