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B-2017-0902CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: CONTRACTOR: PERMIT NO: B-2017-0902 20544 BLOSSOM LN CUPERTINO, CA 95014-4304 (359 18 027) K & M DEVELOPMENT INC CUPERTINO, CA 95014 OWNER'S NAME: SU JERRY C AND KO MENG CHU CATHY OWNER'S PHONE: 408-332-6656 LICENSED CONTRACTOR'S DECLARATION License Class a Lic. #Z4 3J44 Contractor K & M DEVELOPMENT INC Date 10/31/2017 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: r. 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. 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 06-07-2017 OWNER -BUILDER DECLARA 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 sale (Sec.7044, Business & Professions Code) z. 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: r. 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 ISSUED: 06/07/2017 PHONE NO: (408) 390-5127 BUILDING PERMIT INFO: X BLDG X ELECT —PLUMB _ MECH X RESIDENTIAL _ COMMERCIAL JOB DESCRIPTION: POWER POLE (100 AMP) Sq. Ft Floor Area: I Valuation: $400.00 APN Number: Occupancy Type: 359 18 027 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: 06/07/2017 RF—ROOFS: All roofs shall be inspected prior to any roofing material being installed. If a roof is installed without fust obtaining an inspection, I agree to remove all new materials for inspection. Signature of Applicant: Date: 06-07-2017 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, Sections 25505, 25533, and 25534. Owner or authorized age Date: 06-07-2017 t.— N43 -N L Na I hereby affirm that there is a construction lend agency for a performance of work's for which this permit is issued (Sec. 309 , Lender's Name Lender's Address ARCHITECT'S DECLARATION I understand my plans shall be used as public records. Licensed Date 06-07-2017 Professional CUPERTINO GENERAL PERMIT APPLICATION MEP COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 M ' (408) 777-3228 • FAX (408) 777-3333 • building(d-)cupertino.orq 9b 2 S C �5' nPT.IIMFITNG F-1 MECHANICAL ALECTRICAL nMISCELLANEOUS PROJECT ADDRESS ZUs- / /O1'`(`�� APN #^ OWNER NAME j PHO F 33 Ca � _410 E-MAIL STREET ADDRESS ZQ . j / S $ �0✓ Z `y:GL'-� CITY, STATE ZIP , wl�� / /LrJ FAX CONTACT NAME A . r !G� PHONE�i(��'�" E-MAIL STREET ADDRESS /9 CITY, S�,A / V� /7Z FAX ❑ OWNER ❑ OWNER -BUILDER ElOWNERAGENT CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME LICENSE NU BEk LICENSE TYPE BUS. # COMPANY E-MAIL Y.C.J J� C-•• FAX / ��C.. STREET ADDRESS CITY, STATE, ZIP PHONE ARCHITECT/ENGINEER NAME LICENSE NUMBER A BUS. LIC # COMPANY NAME E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE USE OF ❑ SFD or DUPLEX ❑ MULTI -FAMILY BUILDING: ❑ COMMERCIAL PROJECT IN WILDLAND ❑ YES URBAN INTERFACE AREA ❑ NO PROJECT IN ❑ YES FLOOD ZONE ❑ NO IS THE BLDG AN ❑ YES EICHLER HOME? ❑ NO DESCRIPTION JOFFWWORK zoo TOTAL VALUATION: Co RECEI Y: By my signature below, I certify to each of the following: I am the property owner or authorized agent to act on Mpr,opery 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 con tion. I authorize representatives of Cupertino to enter the above -identified roperty for inspection purposes. Signature of Applicant/Agent: Date: L SUPPLEMEN ORM ON REQUIRED OFFICE USE ONLY w ❑ OVER-THE-COUNTER a. F" x ❑ EXPRESS V w x ❑ STANDARD V a ❑ LARGE a ❑ MAJOR MEPMiscApp20II.doc revised 06121/11