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B-2017-0622CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: CONTRACTOR: PERMIT NO: B-2017-0622 10591 GLENVIEW AVE CUPERTINO, CA 95014-4567 (369 26 022) M / C HEATING & COOLING REDWOOD CITY, CA 94063 OWNER'S NAME: KUO CHIN F AND HSU H TRUSTEE DATE ISSUED: 04/20/2017 OWNER'S PHONE: 650-248-6470 PHONE NO: (650) 366-1122 LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: License Class C_-N Lic. #828280 Contractor M / C HEATING & COOLING Date 1.2/31120.17 X BLDG _ELECT _PLUMB I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing X 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: REPLACE A/C (SAME LOCATION) 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 116 Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. Sq. Ft Floor Area: Valuation: $9000.00 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 369 26 022 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 plicant understands and will comply with all non-point source regulatio per the Cupertino Municipal Code, Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION. G Signature Date 4/20/2017 Issued by: AbbyAyende Date: 04/20/2017 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 properly, am exclusively contracting with licensed Signature ofApplicant: contractors to construct the project (Sec.7044, Business & Professions Code). Date: 4/20/2017 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 ofthe 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(a) should I store or handle hazardous material. Additionally, should I use equipment or devices which emit hazardous shall not employ any person in any manner so as to become subject tthe 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 Cu ertino Municipal Code, Chapter 9.12 and exemption, I become subject to the Worker's Compensation provisions of the the Health & Safety Code S ctions 25505, 255335534. Labor Code, I must forthwith comply with such provisions or this permit shall o_,� be deemed revoked. Owner or authorized agent: APPLICANT CERTIFICATION r— Date: 4/20/2017 0 1 certify that I have read this application and state that the above information is CONSTRUCTION LENDING AGENCY 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 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, 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 and will comply with all non-point source regulations per the Cupertino Municipal ARCHITECT'S DECLARATION I understand my plans shall be used .as public records. Code, Section 9.18, Licensed Signature Date 4/20/2017 professional 6-ZO14- owz GENERAL PERMIT APPLICATION E 1 P COMMUNITY DEVELOPMENT. DEPARTMENT • BUILDING DIVISION 10300 TORRE.AVENUE • CUPERTINO, CA 95014-3255 CUPERTI[NO? a 17 PTTTKAI:RTKY� ff&'Z1-.1.At�111T - ncrr_mm�lnAr rl (408) 777-3228 •FAX (408) 777-3333 • buildino(a�cuperfino.or PROJECT ADDRESS Y F -A -PN # f L ^ V [ OWNERNAME W 4 PHON''E r" „�1-1, j(� ` f E-MAIL d `i (J STREET ADDRESS CITY, STATE, ZIP - FAX CONTACT NAME q d _ PHONE e �1 ` �r E-MAIL STREET ADDRESS '.- q� CITY STATE, ZIP L—: 9 ,,'stA s� t X " Y. 6'' �C C` !� �s ® FAx �t ONWER ❑ OWNER -BUILDER ❑ OWNERAGETIT ❑ CONTRACTOR ❑ CON-MACTORAGENT ❑. ARCHITECT ❑s ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME � � �® LICENSE NTLTIvIB� � � � LICENSE TYPE � /J BUS. LIC 4 it COMPANYNA) E ¢ I P ® t l '�P E-MAIL FAX STREET ADDRESS CI STATE. ZIP a PHONE ARCHITE6ENG&TTEER NAME LIC EI"SE NUMBER BUS. LIC f COMPANY NAME E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE USE OF . - [�D o DUTLEX ❑ MULTI -FAMILY BUILDING: ❑ COMMERCIAL PROJECT IN W;tLAND ❑ •YES URBAN DII TERFACE AREA ❑ NO PROJECT IN ❑ YES FLOOD ZONE ❑ No- IS THE BLDG AN ❑ ITS EICHLER HOME? ❑ NO DESCRIPTION OF'WORK TOTAL VALUATION: ® RECEIVEDBY By my signature below, I certify to each f 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 r vided is correct. I have read the Description of Rork and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating b i Ing constructi . I autho ' e resentatives of Cupertino to enter the above -id rtified prop for inspection purposes. Signature of Applicant/Agent: Date: �t SUPP ENTAL INFORMATION REQUIRED oFricEvsEOiLY ❑ OVER=THE COUNTER Eh;STASDARD_:'::; < © LARGE, ❑ Ati470R A1EPAIiscA_pF_2011.doc revised 06/21/11