B-2017-0000 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:
10675 FLORA VISTA AVE CUPERTINO,CA 95014-1610(326 08 013)
OWNER'S NAME: MAHAMONGKOL HATTHAYA AND AMPON DATE ISSUED:
OWNER'S PHONE: PHONE NO:
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class Lic.#
Contractor Date X BLDG 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:
CASE TO DOCUMENT STRUCTURE FIRE AT PROPERTY ON
I hereby affirm under penalty of perjury one of the following two declarations: 4/13/2017
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. Sq.Ft Floor Area: Valuation:$0.00
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 Type:
and state laws relating to building construction,and hereby authorize 326 08 013
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. WITHIN 180 DAYS OF PERMIT ISSUANCE OR
Additionally,the applicant understands and will comply with all non-point
source regulations per the Cupertino Municipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
Signature Date Issued by:
Dater
OWNER-BUILDER DECLARATION
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(Sec.7044,Business&Professions Code). Date:
I hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
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. 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. I 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 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:
APPLICANT CERTIFICATION Date:
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 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 ARCHITECT'S DECLARATION
and will comply with all non-point source regulations per the Cupertino Municipal
Code,Section 9.18. I understand my plans shall be used as public records.
Licensed
Signature Date
Professional
``_ SANTA CLARA COUNTY FIRE DEPARTMENT
� ®��� INCIDENT
U.1 FACT SHEET
Date: April 13, 2017 Time: 5:30 p.m. Information Line: (408) 335-8897
STATUS
Incident Name: Flora Vista
Report Date: 04/13/17 Report Time: 3:57 p.m.
Incident Type: Structure fire
Location: 10000 Block of Flora Vista Ave in Cupertino
Acres: N/A Controlled: N/A
Structures Destroyed: N/A Structures Damaged: 1
Civilian injuries: 0 Firefighter Injuries: 0
Cause: Under investigation Estimated Damage: $1-million
RESOURCES
Total Personnel Assigned: Approximately 40
2-alarms—5 engines, 2 trucks, 2 rescues, 1 haz mat unit, 3 chief officers
Cooperating Agencies: City of Cupertino, Santa Clara County Sheriff
SITUATION
Evacuations: N/A
Road Closures: Flora Vista is currently closed between Gardena Dr and Greenleaf Dr.
Current Situation: At approximately 3:57 p.m. Santa Clara County Fire Department was
dispatched for a structure fire on the 10000 block of Flora Vista Avenue in
the City of Cupertino. Responding units reported smoke visible while en
route, and upon arrival found a 2-story home with a significant working
fire. Firefighters also reported very windy conditions in the area. This is a
working fire and there are currently no reports of civilian or firefighter
injuries, but the family dog is missing. This is the final update pending
any significant changes in the incident.
Approved by: B74/JF
Santa Clara County Fire Department- 14700 Winchester Blvd, Los Gatos, CA 95032 - (408) 378-4010