B-2017-1200CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS:
CONTRACTOR:
PERMIT NO: B-2017-1200
6295 SHADYGROVE CT CUPERTINO, CA 95014-4643 (375 41 028)
DV ELECTRIC CO
SAN JOSE, CA 95132
OWNER'S NAME: SAMET NADAV AND ANTTAL G
DATE ISSUED: 07/24/2017
OWNER'S PHONE: 650-335-5947
PHONE NO: (408)459 Z5T1
LICENSED CONTRACTOR'S DECLARATION
BUILDING PERMIT INFO:
License Class C-10 Lic. #975197
Contractor DV ELECTRIC CO Date '07/31 /2018
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:
PANEL UPGRADE (200 AMP) SAME LOCATION'
I hereby affirm under penalty of perjury one of the following two declarations:
t. 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 andwill 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: $2000.00
permit is issued.
F
i
APPLICANT CERTIFICATION
1 certify that I have, read this application and state that the above
Number:
Occupancy Type:
information is correct. I agree to comply with all city and county ordinances
37541 028
375
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, cost d expenses which
PERMIT EXPIRES IF WORK IS NOT STARTED
may accrue against said City in con equenco a gr nting of this permit.
WITHIN 18O DAYS OF PERMIT ISSUANCE OR
Additionally, the. applicant riders s a clwill cc y with.all non -point
source regulations per! the Cupe 1 iinicip ode, Section 9.18.
180 DAYS FROM LAST CALLED INSPECTION.
SignaturptDate 07-24-2017
Issued by: Kim Dunbar
Date: 07/24/2017
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of the
RE -ROOFS:
All roofs shall be inspected prior to any roofing material being installed. If a roof is
following two reasons
1. I, as owner of the property, 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)
z. Iy as owner of the property, am exclusively contracting with licensed
Signature ofApplicant:
contractors to construct the project(Sec.7044, Business & Professions Code).
Date: 07-24-2017
I hereby affirm under penalty of perjury one of the following three declarations:
I have andmill maintain a�Certificate of Consent to self -insure for Worker's
AL • ROOF COVERINGS TO BE CLASS "A" OR BETTER
t.
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,wiwmaintain 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
a.
perrmt is issued. ;
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
3. I certify that in,the of the work for which this permit is issued, I
Health & Safety Code, Section 25532(a) should I store or handle hazardous
performance
shall:not e! 10,yany person in any manner so as to become subject to the
material. Additionally,should I use equipment or devices which emit hazardous
District
Worker's Compensation laws of California. If, after making this certificate of
air contaminants as defined by the Bay Area Quality Management I
will maintain compliance with the Cuperti unicipal ,Chap r 9.12 and
exemption � I become subject fo the Worker's Compensation provisions of the
the Health & Safety Code, Sec6 2550 533, and 4.
Labor Code, I must forthwith comply with such provisions or this permit shall
be deemed;revoked .
Owner or authorized acren
' ? APPLICANT CERTIFICATION
Date: 07-24-2017
I certify that I have read this application,and state that the above information is
CON CTION LENDING AGENCY
correct. I agree't1 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 bul ng construction, and;hereby authorize representatives of this city
of work's for which this permit is issued (Sec. 3097, Civ C.)
'
to enter upon tfie' 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 thelgrAting of this permit. Additionally, the applicant understands
and will comply with all non -point source; regulations per the Cupertino Municipal
ARCHITECT'DECLARATION
Code, Section.. 1, ' !1 I I
understand my plans shall be used as public records.
Signature Date 07-24-2017
Licensed
Professional
GENERAL PERN41T APPLICATION E
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION M ICP
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
CUPERTINO (408) 777-3228 • FAX (408) 777-3333 • building(Doupertino.org M 11sc
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❑ OWNER ❑ OWNER -BUILDER ❑ OWNER AGENT
❑ CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT
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USE OF ❑ SFT) or DUPLEX ❑ MULTT-FAMILY PROJECT IN WTLDLAND ❑ YES
BUILDING: ❑ COMMERCIAL URBAN INTERFACE AREA ❑ NO
PROJECT IN ❑ YES
FLOOD ZONE ❑ NO' .
Is THE'BLDG AN � El YES
EICHLER HOME?, ! ❑ NO
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DESCRIPTION' OF WORK
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TOTAL VALUATION:
TV Y
By my signature below, I certify to each of the following:
application and the information I have provided is correct
ordinances and state laws relating to building constru
Signature ofApplicant/Ag
I am the property owner or authorized agent to act on the property owner's behalf. I have read this
a ad the Description of Work and verify it is accurate. I agree to comply with all applicable local
. I orize representatives of Cupertino to enter the above-i¢entified pyope rty for inspection purposes.
Date:
SUPPLEMENTAL INFORMATION REQUIRED
OFFICE usE oivLY
W~
❑ OVER TTiE COUNTER
❑ EJ.TRESS Ij.
❑ STANDARD
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❑ LARGE
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❑� MAJOR �
MEPA1iscApp', 2011.doc revised 06/21/11