B-2017-0931CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS:
CONTRACTOR:
PERMIT NO: B-2017-0931
21891 HERMOSAAVE CUPERTINO, CA 95014-2819 (357 16 074)
DALCON
SAN JOSE, CA 95110
OWNER'S NAME: LIU STEPHEN J
DATE ISSUED: 06/12/2017
OWNER'S PHONE:
PHONE NO: (408) 278-1809
LICENSED CONTRACTOR'S DECLARATION
BUILDING PERMIT INFO:
License Class M Lic. #582916
Contractor DALCON Date 12/31/2017
X BLDG X ELECT _PLUMB
—
MECH X RESIDENTIAL COMMERCIAL
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.
JOB DESCRIPTION:
UPGRADE PANEL (400 AMP) - SAME LOCATION; (1) SPA
I hereby affirm under penalty of perjury one of the following two declarations:
DISCONNECT (100 AMP)
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
Sq. Ft Floor Area:
Valuation: $10000.00
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 allcit and county ordinances
APN Number:
Occupancy Type:
and state laws relating to building construction, an hereby authorize
357 16 074
representatives of this city to enter upon the abov mentioned property for
inspection purpgses. (We) agree to save indemni y and keep harmless the
City of Cupertinojagainst liabilities, ipogments, co ts, and eKfo nses which
PERMIT EXPIRES IF WORK IS NOT STARTED
may accrue again t said City in cons quence of _g_gra ng of this permit.
WITHIN 18O DAYS OF PERMIT ISSUANCE OR
Additionally, thea plicant understah s anfLwitl o mply ith all non -point
source regulationg per the Cup ino Municipal ode,. a tion 9.18.
180 DAYS FROM LAST CALLED INSPECTION.
r'
Signature Dat 06-12-2017
Issued by: Kim Dunbar
+
Date: 06/12/2017
I hereby affirI I am xempt from the Contractor's L ense Law for one of the
RF -ROOFS:
following two s: I
All roofs shall be inspected prior to any roofing material being installed. If a roof is
t. I, ae� of e property, or my employ es th wages as their sole
installed without first obtaining an inspection, I agree to remove all new materials for
coa o will do the work, and the structure is not intended or offered for
inspection.
sal.7 4, 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: 06-12-2017
I hereby affirm under penalty of perjury one of the following three declarations:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
i. 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. 1 have and will maintain Worker's Compensation Insurance, as provided for by
I have read the hazardous materials requirements under Chapter .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 25 4. I will
permit is issued.
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
%2
3. I certify that in the performance of the work for which this permit is issued, I
Health & Safety Code, Section 32(.) should I store or handl hazardous
't
shall not employ any person in any manner so as to become subject to the
material. Additionally, should I use �quipment or devices which a hazardous
air contaminants as defined by the B y Area Air Qu Manage ent District I
Worker's Compensation laws of California. If, after making this certificate of
will maintain compliance with the C perdno Mun' fp l Code,,.0 apter 9.12
exemption, I become subject to the Worker's Compensation provisions of the
the Health & Safety Code,3ections 2550 ' 2 3�, and, 534.
Labor Code, I must forthwith comply with such provisions or this permit shall
be deemed revoked.
Owner or authorized agent:
APPLICANT CERTIFICATION
Date: 06-12-2017
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
CON
I hereby affirm that there is a ending agency for the perfo ance
relating to building construction, and hereby authorize representatives of this city
of work's for which this permitc. 3097, Civ C.)
r1ed
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
and will comply with all non -point source regulations per the Cupertino Municipal
ARCHITECT'S DECLARATION
Code, Section 9.18.
1 understand my plans shall be used as public records.
Licensed
Signature Date 06-12-2017
Professional