B-2017-1411CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS:
CONTRACTOR:
PERMIT NO: B-2017-1411
19503 STEVENS CREEK BLVD UNIT 239 CUPERTINO, CA 95014 (316 49 070)
FRANS CARTWRIGHT
SAN JOSE, CA 95133
OWNER'S NAME: HEIN GEORGE B
DATE ISSUED: 08/23/2017
OWNER'S PHONE: 408-5074455
PHONE NO: (408) 250-6672
LICENSED CONTRACTOR'S DECLARATION
BUILDING PERMIT INFO:
License Class C-36 Lic. #828814
Contractor FRANS CARTWRIGHT Date 12/31/2017
X BLDG _ELECT X 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:
(N) 50 GALLON WATER HEATER IN SAME LOCATION -CLOSET
I hereby affirm under penalty of perjury one of the following two declarations:
t. Lhave and will maintain a certificate of consent to self -insure for Worker's
Compensation, as provided for 1 y Section 3700 of the Labor Code, for the
erformmce of the work for which this permit is issued.
have and will maintain Worker's Compensation Insurance, as provided for by
Se tion 3700 of the Labor Code„ for the performance of the work for which this
Sq. Ft Floor Area:
Valuation: $2300.00
rmit 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
316 49 070
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 inconsequence of the granting of this permit.
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
Addition the applicant understands and will comply with all non -point
source a ulations per the Cupe ' o Municipa Code, Section 9.18.
180 DAYS FROM LAST CALLED INSPECTION.
S' •,;-a; ? Date 8/23/2017
Issued by: Jasmine Archbold
0
Date: 08/23/2017
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. 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: 8/23/2017
I hereby affirm under penalty of perjury one of the following three declarations:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
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.
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. 1 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
Worker's Compensation laws of California. If, after making this certificate of
air contaminants as defined b the Bay Area Air Quality Management District I
will maintain compliance the Cupertino Municipal Code, Chapt r 9.12 and
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
h & Saf ty ode Se tions 25 05, 733, and 255
0"Ihorized
be deemed revoked.
O ag t:APPLICANT
CERTIFICATION
23 1
I certify that I have read this application and state that the above information is
CONSTRUCTION LENDING AGENCY
Lrformance
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
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.
I understand my plans shall be used as public records.
Signature Date 8123/2017
Licensed
Professional
GENERAL PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
C.UPERTIIVO (408) 777-3228 • FAX (408) 777-3333 • buildinaCokupertino.om
PLUMBING ❑MECHANICAL ❑ELECTRICAL
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MISC
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PROJECT ADDRESSQ
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STREET ADDRESS
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USE OF ❑ SIT) or DUPLEX
MULTI -FAMILY
PROJECT IN WILDLAND ❑ YES
PROJECT IN ❑ YES
IS THE BLDG AN ❑ YES
BUILDING: ❑ COMMERCIAL
URBAN INTERFACE AREA NO
FLOOD ZONE O
EICHLER HOME? NO
DESCRIPTION OF WORK
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TOTAL VALUATION:
RECEIVED B
By my signature below, I ce fy o each of the following: I am the property owner or thorized agent to act on the property owner's behalf. I have read this
d the Descripti o Work and verify it is accurate. I agree to comply with all applicable local
application and the inform ion I have p vided is correct. baq0r
ordinances and state laws latin to u' in .c ctio epr sen ti es Cupertino to enter the ab ove=iden 'fled p perry for inspection purposes.
Signature ofApplicanUAg t
Date: I ��
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INFORMATION REQ D
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MEPMiscApp 2011.doc revised 06/21/11
UM
21