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B-2017-0470CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: CONTRACTOR: PERMIT NO: B-2017-0470 10466 MILLER AVE CUPERTINO, CA 95014-3428 (375 05 037) JAY KATS INC SUNNYVALE, CA 94089 OWNER'S NAME: BIALOGLOVSKI ELIZABETH M OWNER'S PHONE: 408-234-6790 LICENSED ONT TOR' R TION License Class CC -10 Lic. #1004332 Contractor JAY KATS INC Date 06/30/2017 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. I hereby affirm under penalty of perjury one of the following two declarations: 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. �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) ria" save indemnify and keep harmless the City of Cupertino againsUilbilniesjjludgments, costs, and expenses which may accrue against s I'd City in asequence of the granting of this permit. Additionally, the a, - icant undQ��s and will comply with all non -point source regulatio . s per the C e o M_Wlicipal Code, Section 9.18. 03-23-2017 I hereby affwdlthat 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 sale (Sec.7044, Business & Professions Code) 2. I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec.7044, Business & Professions Code). 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 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 Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. 3. I certify that in the performance of the work for which this permit is issued, I shall 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 an&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 03-23-2017 ISSUED: 03/23/2017 PHONE NO: (650) 766-6196 BUILDING PERNHT INFO: X BLDG X ELECT _ PLUMB _ MECH X RESIDENTIAL _ COMMERCIAL JOB DESCRIPTION: PANEL UPGRADE (200 AMP) CUPERTINO BUS LIC - 403078 3/23/2018 Sq. Ft Floor Area: Valuation: $1000.00 "N Number: Occupancy Type: 375 05 037 PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTION. Issued by: Kim Dunbar Date: 03/23/2017 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. Signature of Applicant: Date: 03-23-2017 ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER HAZARDOUS MATERIALS DISCLOSURE I have read the hazardous materials requirements under Chapter 6.95 of the California Health & Safety Code, Sections Z5505,25533, and 25534. I will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Section 25532(a) shouldtoff a or handle hazardous material. Additionally, should I use equipmen r doYices which emit hazardous air contamfnants as defined by the Bay Are Air Qiality Management District I will maintain compliance with the Cupe • no ipal Code, Chapter 9.12 and the Health & Safe Code, c . 5 55 , and 25534. Owner or authorized agent: ` t Date: 03-23-2017 /. I hereby affirm that there isp con tfuction lending agency for the performance of work's for which this per issued (Sec. 3097, Civ C.) Lender's Name Lender's Address ARCHITECT'S DECLARATION I understand my plans shall be used as public records. Licensed Professional CUPERTINO GENERAL PERMIT APPLICATION MEP COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 • buildingaa cursertino.ora MISC yyp j C7lPLUMBING MECHANICAL P ELECTRICAL ❑MISCELLANEOUS PROJEC AD➢REBS i o I' ,I � 6 PrI 1 [ I n n/ Ave, V" I 0 J/ 1. 1�„/ r 7 APN # - j - OWNERNAME j � a j K} o `, �l PHONE L� ^�lJ, - E MAU J t �7 Ill j f C STREET ADDRESS 9 �I� de t t // YeqI-CITY, STATE, ZIP S 1 s `� G (� 6v( FAX 9 4� CONTACT NAME n V vv PHONE E-MAIL STREET ADDRESS 'rek to QA ,7 ,¢ a C CITY, VQ OWNER Q OWNER-BUB.DER Q OWNER AGENT 13 CeONTRACTOR QCONTRACTOR AGENT Q ARCIirrECr ENGINEER Q DEVELOPER Q TENANT CONTRACTOR NAME LLICENSE NUMBERI i c ep �^ _ i F1 BUS. LIC # COMPANY NAME ,LIICiEN}-S�E�TYPE p r 10 E-MAIL �u ° F b"lJ�l�4J$ t`W'l 9 FAX STREET ADDRESS C/+ CITY, STATE, ZIP -qu nn ttls r vq L G �so`R� PHONE �`�7— =} 6 —6161 ' ARCHITECT/ENGINEER NAME JCENSE NUMBER BUS. LIC # COMPANY NAME E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE USE OF FD or DUPLEX MULTI -FAMILY BUILDING: QCOMMERCIAL PROJECT IN wILDLAND Q YES URBAN INTERFACE AREA �NO PROJECT IN Q YES FLOOD ZONE eEl"NO IS THE BLDG AN Q YES EICHLER HOME? ® NO DESCRIPTION OF WORK T)CA V?C� J � I L ICA TOTAL VALUATION: ®Q RE By - By my Signature below, I cer&y 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 cotTect. I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating to building construction. I authorize representatives of Cupertino to enter the above -I ntified operty for inspection purposes. Dater Signature afApplicant/Agent: _— SUPPLEMENTAt INFORMATION REQUIRED OFFICE USE ONLY � a, ❑ OVER-TIIE-COUNTER EXPRESS D STANDARD © LARGE ® MAJOR MEPMI=App 201 Ldoe revised 06121111 )r