B-2017-1355CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS:
CONTRACTOR:
PERMIT NO. B-2017-1355
20091 NORTHWOOD DR CUPERTINO, CA 95014-0554 (316 36 042)
MAINE ELECTRIC INC
LIVERMORE, CA 94551
OWNER'S NAME: FUKUMA HAROLD E TRUSTEE
DATE ISSUED: 08/15/2017
OWNER'S PHONE: 408-255-4909
PHONE NO: (925) 443-3377
LICENSED CONTRACTOR'S DECLARATION
BUILDING PERMIT INFO:
License Class C10 Lic. #830250
Contractor MAINE ELECTRIC INC Date 04/30/2019
X BLDG X ELECT —PLUMB
—
MECH X RESIDENTLAI. 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:
REPLACE SUB-PANEL (100 AMP) IN GARAGE
I hereby affirm under penalty of perjury one of the following two declarations:
t. I have and will maintains 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: $3666.00
permit is issued.
APPLICANT CERTIFICATION
I certify that I haveread 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
316 36 042
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.
Signatu Date 08-15-2017
Issued by: Kim Dunbar
Date: 08/15/2017
OWNER-BUILDER DTO
I hereby affirm, that I yam 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
i. 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)
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: 08-15-2017
I hereby affirm under penalty of perjury one of the following three declarations:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
m. 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
performance of the work'for which this permit is issued.
HAZARDOUS MATERIALS DISCLOSURE
z. 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
rm
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
s. 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
F
maternal. Additionally, should 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 Qde, Sections 25505, 25533, and 25534.
Labor Code, I must forthwith comply with such provisions or this permit shall
be deemed revoked.
Owner or authorized ag
APPLICANT CERTIFICATION
Date: 08-15-2017
I certify that I have read this application and state that the above information is
correct. f 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.
Signature Date 08-15-2017
Licensed
Professional
GENERAL PERMIT APPLICATION MEP
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 Isc CUPERTINO (408) 777-3228 - FAX (408) 777-3333 • buildingCa�cupertino.oag
3 -6 -135
I—I PLUMBING ❑ MECHANICAL 54LECTRICAL ❑ MISCELLANEOUS
PROJECT ADDRESS WOQ 1 -�
f/
APN # G, ` O
2
IIPHI
OWNER NAME ��f T`-' Ir , IM n
` I0:V
•Z 5 ' O o
E-MAIL
STREETADDRESS �vv f' I v1_�F�^�V
I I`
CI�} earr t,v� e A �15��
FAX
;CONTACT NAME JEFF RAINNEY
PHONE 510-427-4260
E -MAH'
jeffrey.rainey@aft.net
sTREETADDREss 1069 EDGEMERE LANE
crrY,sTaTE, ZIP HAYWARD, CA 945454
FAX
510-783-1041
❑ OwNER ❑ OwNER-BUJLDER ❑ OWNERAGENT
❑ CONTRACTOR W CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT
,CONTRACTOR NAME
LICENSENUMBER v J c ^
L
LICENSE TYPE eI o
BUS. LIC #
COMPANYNAME
)MAWC,ef CZ%ZIC
E-MAIL
FAX
zs , . 3- 337
STREET ADDRESSS q
CITY, STATE, ZIP
alS'� f
PHONE
2 S • '-f 3.33 %
ARCHITECT/ENGINEER NAME
LICENSE NUMBER
BUS. LIC #
COMPANY NAME
E-MAIL
FAX
STREET ADDRESS
CITY, STATE, ZIP
PHONE
USE OF ❑SFDorDUPLEX MULTI -FAMILY
BUILDING: ❑COMMERCIAL
PROJECT IN WILDLAND ❑ YES
URBAN INTERFACE AREA ❑ NO
PROJECT IN ❑ YES
FLOOD ZONE ❑ NO
ISTHEBLDGAN ❑ YES
EICHLERHOME7 ❑ NO
DESCRIPTION OF WORK
TOTAL VALUATION:3
RECEIV ,
By my signature below, I certify to each of the following: I am the property owner or authorized agent to act on the property owner'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
;ordinances and'state laws relating to building construction. I authorize representatives of Cu e nterttre above -identified property for inspection purposes.
Signature o f ApplicanUAgent: Date:
ENTAL INFO QUIRED
, ' 'OFFICE USE ONLY
W
�
OVER-tHE-COUNTER
❑EXPRESS . r
D;STANDARD '
-LARGE
MAJOR
MEPMiscApp 2011.doc revised 06/21/11
FL
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