B-2017-1040CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS:
CONTRACTOR:
PERMIT NO: B-2017-1040
11699 OLIVE SPRING CT CUPERTINO, CA 95014-5141 (366 54 098)
T B S CONSTRUCTION
INC
SANTA CLARA, CA
95054
OWNER'S NAME: JAKHUAZVIAD
DATE ISSUED: 06/29/2017
OWNER'S PHONE: 408-504-3534
PHONE NO: (408) 824-8888
LICENSED CONTRACTOR'S DECLARATION
BUILDING PERMIT INFO:
License Class a Lic. #903870
Contractor T B S CONSTRUCTION INC Date 09/30/2017
X BLDG _ELECT X PLUMB
Y hereby affirm that I am licensed under the provisions of Chapter 9 (commencing
X MECH X RESIDENTIAL _ COMMERCIAL
with Section 7000) of Division 3 of the Business & Professions Code and that my
license is in full force and effect.
JOB DESCRIPTION:
INSTALL (1) BACK UP GENERATOR; (1) 1" POLYETHELENE GAS
I hereby affirm under penalty of perjury one of the following two declarations:
LINE - - GENERATOR (1000 BTU)
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.
Sq. Ft Floor Area:
Valuation: $10000.00
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
and state laws relating to building construction, and hereby authorize
366 54 098
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
PERMIT EXPIRES IF WORK IS NOT STARTED
may accrue against said City in consequence of the granting of this permit.
Additionally, the applicant understands and will comply with all non -point
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
source regulations per the Cupertino Code, Section 9.18.
180 DAYS FROM LAST CALLED INSPECTION.
Signaturej Date 6/29/2017
Issued by. Abby Ayende
G
;
Date: 06/29/2017
OWNER -BUILDER, DECLARATfON
I hereby affirm that I am exempt from the Contractor's License Law for one of the
RE -ROOFS:
following two reasons:
All roofs shall be inspected prior to any roofing material being installed. If a roof is
1. I, as owner of the properly, or my employees with wages as their sole
installed without first obtaining an inspection, I agree to remove all new materials for
compensation, will do the work, and the structure is not intended or offered for
inspection.
sale (Sec.7044, 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: 6/29/2017
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.
HAZARDOUS MATERIALS DISCLOSURE
2. I have and will maintain Worker's Compensation Insurance, as provided for by
I have read the hazardous materials requirements under Chapter 6.95 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 25534. I will
permit is issued.
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
3. I certify that in the performance of the work for which this permit is issued, I
Health & Safety Code, Section 25532(a) should I store or handle hazardous
shall not employ any person in any manner so as to become subject to the
material. Additionally, should I use equipment or devices which emit hazardous
air contaminants as defined by the Bay Area Air Quality Management District I
Worker's Compensation laws of California. If, after making this certificate of
will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and
exemption, I become subject to the Worker's Compensation provisions of the
the Health & Safety Code, Sections 25505, 25533, and 25534.
Labor Code, I must forthwith comply with such provisions or this permit shall
4
be deemed revoked.
Owner or authorized agent:
APPLICANT CERTIFICATION
,Date: 6/29/2017
1 certify that I have read this application and state that the above information is
CONSTRUCTION LENDING AGENCY
correct. I agree to comply with all city and county ordinances and state laws
I hereby affirm that there is a construction lending agency for the performance
relating to building construction, and hereby authorize representatives of this city
of work's for which this permit is issued (Sec. 3097, Civ C.)
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 M290 17
Professional
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GENERAL PERMIT APPLICATION un
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION M Em P
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
CUPE TING - % �
PLUMBING �IMECHANTCAL 1 IF.i.F( TRi�Ai" �it�rrcrFr r ewpnTTc
(408} 777-3228 •FAX (408} 777-3333 • buildinc�C.�cuperlirla.ar
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❑ OWNER ❑ OWNER -BUILDER ❑ OWNER AGENT -0-CONTRACTOR. CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAMI[t
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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 OF WORK
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TOTAL VALUATION- 10000
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 own '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
property for inspection purposes.
ordinances and state laws relating to lding c n cfio uthorize representatives of Cupertino to enter the aboye�i entifi717
Signature of Applicant/Agent: Date:
SUPPLEMENTAL INFORMATION REQUIRED
oricE USE ONLY .
DYER_THE-COUN"FER
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MEFMiscApp_201 Ldoc revised 06/21/11
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License #w
r ' ` aGppi�ils of d#twiled drawings, blueprints, photos, brochunss, and any paint colors of your Plan(s)
t urida1, tend ittat under the declaration and the rules regulations, the Board of Directors -will act on this request and
provrda rise riv h a: vrrifien response of their, dee ion, I, further understand and agree to the , Rowing provision$,
1 r No'work-:air carniriitmant of work will bwmade by:isie unfit t have received written approval fromthe association,
2 AIi'twcuk wlii be: done at my. e�ense ani e!f fiuture upkeep will remain at my expense,
3 =wor% itiill be -dune expeditlQ rsly.once commenced and Will be done in a good workman -like manner by myself or a
4 Ails ork will be.po formed. ata time and in a manner to minimize interference and inconvenience to other unit owners.
5: °1= t►te a�ll"iiabilrty and will be responsitsle Tai• all damage and/or injury which may result from performance of this work
8 ! syrll ` responaibie for the conduct of all persons, agents. contractors, and employees who are connected with this work
j . i u `: nd and agree that the Association, Its Board of Directors and the Management Company have no responsibility
with pact to such compliance and that the Bowrd of Directors` or its designated committees` approval of this request
shaii�ot brunsiersoo€1 ais tiewkeng of any, reptesentwron or warranty that tha plans speciTrc:aatians,`:arvork comply
� �u"tattoo offoverrimexntsf regtiirer>aerk ' "'
. , __° o _ori nas t f /` Ay days ffam recwiptxo *view the architectural_request:
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'd L3 ators t)»ly Apprs�,vi d. APP rcYed w1+Conditions Denied -
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