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B-2017-0837CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: CONTRACTOR: PERMIT NO: B-2017-0837 19800 VALLCO PKWY CUPERTINO, CA 95014 (316 20 108) AMERICAN WATER HEATER SERVICE INC NEWARK, CA 94560 OWNER'S NAME: CUPERTINO PROPERTY DEVEL I LLC DATE ISSUED: 06/28/2017 OWNER'S PHONE: 408-858-0065 PHONE NO: (5 10) 490-4411 LICENSED CONTRACTOR'S DECL.ARRATION BUILDING PERMIT INFO: License Class BOILER, HOT WATER HEATING AND STEAM FITTING Lic. X BLDG —ELECT —PLUMB #959436 Contractor AMERICAN WATER HEATER SERVICE INC Date 03/31/2019 X MECH X RESIDENTLAL_ 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 JOB DESCRIPTION: license is in full force and effect. INSTALL EXHAUST INDUCERS I hereby affirm under penalty of perjury one of the following two declarations: NAA A0 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. 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: $3000.00 permit is issued. APPLICANT CERTIFICATION I certify that I have read this application and state that the above APN Number: Occupancy Type: information is correct. I agree to comply with all city and county ordinances 31620 108 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 PERMIT EXPIRES IF WORK IS NOT STARTED City of Cupertino against liabilities, judgments, costs, and expenses which WITHIN 180 DAYS OF PERMIT ISSUANCE OR may accrue against said City in sequen f the granting of this permit. Additionally, the applicant u tands a ill comply with all non-point 180 DAYS FROM LAST CALLED INSPECTION. source regulations per th pertino cipal ode, Section 9.18. Issued by: Abby Ayende Signat Date 6/28/2017 Date: 06/28/2017 -1, DEC ARATION I hereb a rm that I am exempt from the Contractor's License Law for one of the RE-ROOFS: All roofs shall be inspected prior to any roofmg material being installed. If a roof is following two reasons: installed without first obtaining an inspection, I agree to remove all new materials for r. I, as owner of the property, or my employees with wages as their sole inspection. compensation, will do the work, and the structure is not intended or offered for sale (Sec.7044, Business & Professions Code) Signature of Applicant: 2. I, as owner of the property, am exclusively contracting with licensed Date: 6/28/2017 contractors to construct the project(Sec.7044, Business & Professions Code). I hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER 1. 1 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 HAZARDOUS MATERIALS DISCLOSURE performance of the work for which this permit is issued. I have read the hazardous materials requirements under Chapter 6.95 of the 2. I have and will maintain Worker's Compensation Insurance, as provided for by California Health & Safety Code, Sections 25505, 25533, and 25534. I will Section 3700 of the Labor Code, for the performance of the work for which this maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the permit is issued. Health & Safety Code, Section 25532(a) should I store or handle hazardous 3. I certify that in the performance of the work for which this permit is issued, I material. Additionally, should I use equipment or devices which a ardous shall not employ any person in any manner so as to become subject to the air contaminants as defined by the Bay Area Air Quality Manag a istrid I will maintain compliance with the Cupertino icipal Code h ter 9.12 and Worker's Compensation laws of California. If, after making this certificate of the Health & Safety Code, Sectio 505, 25533 n 5534. 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 Owner or authorized ag eft be deemed revoked. Date: 6/28/2017 APPLICANT CERTIFICATION T I I certify that I have read this application and state that the above information is I hereby affirm that the a is onstruction lending agenPyfrthperformance correct. I agree to comply with all city and county ordinances and state laws of work's for which thidporrhit is issued (Sec. 3097, Civ C.) relating to building construction, and hereby authorize representatives of this city Lender's Name to enter upon the above mentioned property for inspection purposes. (We) agree 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 ARCHITECT'S DECLARATION and will comply with all non-point source regulations per the Cupertino Municipal I understand my plans shall be used as public records. Code, Section 9.18. Licensed Professional Signature Date 6/28/2017 GENERAL PERMIT APPLICATION . MEP COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 CUPERTINO (408) 777-3228 • FAX (408) 777-3333 • build ino(Q7cuaertino.org misc ❑ PLUMBING MECRANICAL ,--j laLECTRICAL ❑ MISCELLANEOUS PROJECT ADDRESS 5 l l{'J APN # �.® �„ OV f OWNERNA PHONFL Q' (� 06 p (/I E-MAIL STRHEr ADDRE I 60 CITY, STATE, ZIP L J FAX CONTACT NAME PHONE E-MAIL STREET ADDRESS CITY, STATE, ZIP FAX 11OWNER 11OWNER-BUILDER El OWNER AGENT /• I CONTRACTOR ❑ CONTRACTORAGENT ❑ ARCHITECT ❑ ENaiNmR ❑ DEVELOPER ❑ TFNANT CONTRACTOR NAME . pts .� !1 . 4 LIC E ` Iv+ LICENSE TYPE BUS. LIC # COMPANYNAtJlE-�fI.{/ •� S�VCJ LfAivl ttJtI ,vUw 4L FAX Al STREET ADDRESS TJ;(+ CITY, SUB ZIP /J, �� S6y� �f'T V PHONE ARCHITECT/ENGINHERNAME LICENSENUMBER BUS. LIC# COMPANY NAME B -MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE USE OF ❑ SPD orDUPLEX ❑ MULTI -FAMILY BUJrPING: ❑COMMERCIAL PROJECT IN WILDLAND ❑ YES URBAN INTERFACE AREA ❑ NO PROJECT IN ❑ YES FLOOD ZONE ❑ NO IS THE BLDG AN ❑ YES EICHLERHOME7 ❑ NO DESCRIPTION OF WORK S e 6± ALUATION:V 1 OD TOTAL VALUATION:-1:0001 14 R EC BY: ani the ,l� rty owner or authorized agent t act on the property owner's behalf. I have read this Dy my signature below, I certify to each of the Z-iioit�] application and the information I have provided have ��d the Description of Work and verify it is accurate. T agree to comply with all applicable local ordinances: and state laws relating to building caI 6rize representatives of Cupertino to enter the above tified npelTy for inspection Innposes. Signature ofAppheant/Agent: Date: O S M TAL OR B QUIRED OFFICE USE ONLY w 0 OVER-THE-COUNTER © EXPRESS VUW x ❑ STANDARD V El LARGE a MAJOR MEPMPsc,Ipp_2011,doc revised 06/21/11