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B-2017-0642CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: CONTRACTOR: PERMIT NO: B-2017-0642 18870 TUGGLE AVE CUPERTINO, CA 95014-3626 (375 32 024) GURRIES ELECTRIC INC SAN JOSE, CA 95161 OWNER'S NAME: DELA CRUZ SHERWIN P L OWNER'S PHONE: 650-281-1520 LICENSED CONTRACT'OR'S DECLARATION License Class C-1 Lic. #912358 Contractor GURRIES ELECTRIC INC Date 04/30/2018 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. DATE ISSUED: 04/24/2017 PHONE NO: (408) 710-4251 BUILDING PERMIT INFO: BLDG X ELECT _ PLUMB MECH X RESIDENTIAL COMMERCIAL JOB DESCRIPTION: TEMP POWER POLE (125 AMP) I hereby affirm under penalty of perjury one of the following two declarations: t. 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. 10 z. 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) 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 pet the Cupertino Municipal Code, Section 9.18. 1 Signatures iDate 04/24/2017 I hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: t. , 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 Sq. Ft Floor Area: l Valuation: $500.00 1APN Number: Occupancy Type: 37532024 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: 04/24/2017 RF 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. sale (Sec.7044, Business & Professions Code) 2. I, as owner of the property, am exclusively contracting with licensed Signature ofAppl contractors to construct the project (Sec.7044, Business & Professions Code). Date: 04/24/2017 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 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 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) 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 04/24/2017 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 25505, 25533, and 25534. I will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Section 25532(a) should I store or handle hazardous material. Additionally, should I use equipment or devices which emit hazardous - air contaminants as defined by the Bay Area Air Quality Management District I will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and' the Health & Safety Code, Secti s 25505, 25533, and 25534. Owner or authorized age Date: 04/24/2017f —_—_ CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of work's for which this permit is 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 GENERAL PERMIT APPLICATION mEvi:. I COMMUNITY DEVELOPMENT. DEPARTMENT • BUILDING DIVISION 10300 TORRE.AVENUE • CUPERTINO, CA 95014-3255 LtPEFi�[I�Q (408) 777-3228 •FAX (408) 777-3333 • buildino(a cupertino.or-g PLUMBING I IMR.rT-TANIrAT- I;KIA7rTRTrAT I—IIfTcrrTT m I S n��c rTO PROJECT ADDRESS � V APN OWNTER NAME �. ' N. PHOvE( Ep CAU � � E-MAIL STREET .ADDRESS �Tj CITY, STATE,�P llil` �4 FAX CONTACT NA.�4E � � ( �f �`� PHOIv'E � � � ' � EMAIL - STREET ADDRESS �t ; • , e CITY, STATE, ZIP FA, ❑ OWNER ❑ OWNTER-BUILDER ❑ OWNE'AGENT [�-CONTRACTOR ❑ CONTRACTOR AGENT ❑, ARCHITECTt ❑ ENGINEER ❑ DEVELOPER ❑ "TENANT CONTRACTOR NAME ft oy 'Y LICENSE NUMBER I I � '{ r LICENSE TYPE �� coMPANYNAnE ok E- �1� 1 1 BUS. LIC ( 'x Y `' STREET ADDRESS p { � �If}�q� jf� i 41 •CITY, STATE, ZIP PHON\ 40bj I (J �, 1 46! ARCHITECTIENGINEER NAME LICENSE NUMB" BUS. LIC # COMPANY NAME E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE USE OF . '. V SFD or DUPLEX ❑ MULTI -FAMILY BUILDING: ❑COMMERCIAL PROJECT IN W7tLAN-D ❑ •YES URBA```N��INTERFACEAREA ❑ NO PROJECT IN ❑ YES FLOOD ZONE ❑ NO IS THE BLDG AN ❑ 1 -L -S EICHLERHOME? ❑ NO DESCRIPTION OF WORK TOTAL VALUATION; By my signature below, I certify to each of the following: I am the property owner or authorized agent to actlin e property owner's behalf. I have read this application and the information I have provided is correct. 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 toenter the above- den , fied p}r pjerty for inspection purposes. Signature of Applicant/Agent: Date: k 1 SUPPLEMENTAL INFORMATION REQUIRED aFrc usE`anI i ER THE COIJ�\TER EXPRESS - ..: STA''DARD 4 L4RGE- TZAJOR hfEPA7iscApp_2011.do0 revised 06/21/11 I'm