B-2017-0744CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO: B-2017-0744
18890 BARNHART AVE CUPERTINO, CA 95014-3602 (375 33 011) CIIUEN YANG YANG
SAN LEANDRO, CA
94579
OWNER'S NAME: RAI NIRAJ AND AGRAWAL LORI
OWNER'S PHONE: 408-799-8605
LICENSED CONTRACTOR'S DECLARATION
License Class 5 Lie. #897965
Contractor CHUEN YANG YANG 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
DATE ISSUED: 05/10/2017
PHONE NO: (510) 213-9981
BUILDING PERMIT INFO:
X BLDG X ELECT _ PLUMB
_ MECH X RESIDENTIAL _ COMMERCIAL
JOB DESCRIPTION:
(N) TEMPORARY POWER POLE (100 AMPS)
Compensation, as provided for by Section 3700 of the Labor Code, for the
performance of the work for which this permit is issued.
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. Sq. Ft Floor Area: Valuation: $1500.00
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
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
APN Number: Occupancy Type:
37533 011
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
Date 5/10/2017 Issued by: Abby Avende
Date: 05/10/2017
I hereby affirm that 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).
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: 5/10/2017
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 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.
s. 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 Califonria. 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 5/10/2017
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, Sections 25505, 25533, and 25534.
Owner or authorized agen VZ16tn 4,
Date: 5/10/2017
N Y
I hereby affirm that there is a construction lending agency f the performance
of work's for which this permit is issued (Sec. 3097, C'
Lender's Name
Lender's Address
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Licensed
Professional
B-Zoli- oqqq
GENERAL PERMIT APPLICATION MEP
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 1 R r.
CUPERTINO
❑ PLUMBING ❑ MECHANICAL ❑ ELECTRICAL MISCELLANEOUS
(408) 77? -3228 •FAX (408) 777-3333 • buiidina(a.cu�ertino.ora
PROJECT ADDRESS
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u OWNER ❑ ONT'ER-BuiLDER ❑ OWNERAGENT
❑ CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGLNTER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME ` ^ `
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LICENSE NUM24 4 BER �^
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LICENSE TYPES
BUS. LIC 3� 35
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ARCAITECT/ENGINNEER NAME
LICENSE NUMBER
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STREET ADDRESS
CITY, STATE, 'LIP
PHONE
USE OF ❑ SFD o DUPLEX ❑ MULTI -FAMILY PROJECT A' WIIALAN'D ❑ ITS
BUILDING: ❑ COMMERCIAL URBAN INTERFACE AREA ❑ NO
PROJECT IN ❑ YES
FLOOD ZONE 2---qb
IS THE BLDG AN ❑ YES
EICHLER HOME? &-No
DESCRIPTION OF WORK
TOTAL VALUATION: /' %/
RECEIVED BY:
By my signature below, I certify to each of the following: I am the property owner or authorized agent to act on the property owner's be calf. I have read this
ded is correct. I have read the Description of \Fork and verify it is accurate. I a reg to comply with all applicable local
application and the information I ha/.-
ordinances and state laws relating tg construction. I authorize representatives of Cupertino to enter the abov dentrf d property for inspection purposes.
Signature of Applicant/Agent: Date: U/y Z /
SUPPLEME AL
001 ATI REQUIRED
OFFICE USE ONLY
OVER-THE-COUNTER
F'
❑ EXPRESS
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STANDARD
El LARGE
El AlUOR
A1EPA1iscApp_201 T doe revised 05/21/11