B-2017-1249CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS:
CONTRACTOR:
PERMIT NO: B-2017-1249
10201 IMPERIAL AVE CUPERTINO, CA 95014 (357 18,006)
GOGO ROOTER
SAN JOSE, CA 95112
OWNER'S. NAME: SARATOGA CUPERTINO COLUMBIAN CO INC
DATE ISSUED: 07/31/2017
OWNER'S PHONE:
PHONE NO: (408) 282-7025
LICENSED CONTRACTOR'S DECLARATION
BUILDING PERMIT INFO:
License Class Q Lic, #939034
Contractor GOGO ROOTER Date 10/31/2017
X BLDG —ELECT X PLUMB
—
MECH RESIDENTIAL X 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:
CLEANOUT 2 WAY
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
C017plMsation, as provided for by Section 3700 of the Labor Code, for the
ormance of the work for which this permit is issued.
ave 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: $2800.00
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 all city and county ordinances
APN Number:
Occupancy Type:
and state laws relating to building construction, and hereby authorize
357 18 006
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.
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
Additionally, the applicant understands and will comply with all non -point
source regulations per, the Cupertino Municipal Code, Section 9.18.
180 DAYS FROM LAST CALLED INSPECTION.
AEOW ""
Date 713/2017
Issued by: JASMINE ARCHBOLD
Date: 07/31/2017
OWNER -BUILDER DECLARATION
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
t. 1,; 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)
2. I, as owrier of the property, am exclusively contracting with licensed
Signature of Applicant:
contractors to construct the project (See.7044, Business & Professions Code).
Date:17/3 /2017
I hereby affirm under penalty of perjury one of the following three declarations:
2. I have and will maintain a Certificate of Consent to self -insure for Worker's
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
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
be deemed revoked.
r ltonzed agent:
APPLICANT CERTIFICATION
ine
t .4 2 1I
Zj (� PCONSTRUCTION LENDING AGENCY
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
reby affirm{ that there is a construction lending agency for the performance
-3097,
relating to building construction, and hereby authorize representatives of this city
of work's for which this permit is issued (Sec. 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.
Signature Date 7/31/2017
Licensed
'Professional
CUPERTINO
GENERAL PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228 e FAX (408) 777-3333 • building a,cupertino.org
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❑ OWNER ❑ OWNER -BUILDER ❑ OWNER AGENT L1 CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAM
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USE OF ❑ SFD or DUPLEX El' MULTI-FAMTLY
BUILDING: ❑ COMMERCIAL
PROJECT IN WILDLAND ❑ YES
URBAN 94TERFACE AREA ❑ NO
PROJECT IN ❑ YES
FLOOD ZONE ❑ NO
is THE BLDG AN ❑ YES
EICHLER HOME? ❑ NO
DESCRIPTION OF WORK
,I
I
TOTAL VALUATION O
RECErvED.BY
13y my signature below, I certify to eaich of the following: I am the property owner or authorized agent to act on the property owner's behalf. L have read this
application:and theEinformation I have provided is correct. I have rea the Description of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating to bttildin construo�n. A2authoriz represe tatives of Cupertino to enter the above p�op�riyorynspection purposes.
Signature of Applicant/Agent: 6 ' l v v/� �V Date:/�j_
SUPPLEMENTAL INFORMATION REQUIRED
oFFrcE USE on2Y
w
' ❑ OVER THE COUI\ER
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EaTRESS
❑ STANDARD
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❑ LARGE
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❑ MAJOR
MEPMiscApp_2011.doc revised 06/21/11