B-2017-0231 I
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2017-0231 '
7525 ORANGE BLOSSOM DR CUPERTINO,CA 95014-5224(366 11 050) PROVISION
DEVELOPMENT INC
' SUNNYVALE,CA
94085
OWNER'S NAME: CHANG KUO-WEI AND CHEN WAN-LIN TRUSTEE DATE ISSUED:09/21/2017 i
i
OWNER'S PHONE: PHONE NO:(408)245-0991 1
I
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class a Lic.#858391 {
Contractor PROVISION DEVELOPMENT INC Date 05/31/2019 X BLDG X ELECT X PLUMB I
I 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 i
license is in full force and effect. JOB DESCRIPTION:
1ST FLOOR LIVING ROOM,BEDROOM ADDITION,BATHROOM,
I hereby affirm under penalty of perjury one of the following two declarations: STUDY ROOM ADDITION(725 S.F.);FRONT COVERED PORCH(57.5
1. I have and will maintain a certificate of consent to self-insure for Worker's S.F.);REPLACE(1)WINDOW IN MASTER BEDROOM;REPLACE I
Compensation,as provided for by Section 3700 of the Labor Code,for the FURNACE AT INTERIOR CLOSET;(N)TANKLESS WATER HEATER
performance of the work for which this permit is issued. IN GARAGE;UPGRADE ELECTRICAL METER/PANEL(200 AMP). I
( 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:725 Valuation:$105000.00
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above I
information is correct.I agree to comply with all city and county ordinances APN Number: Occupancy Type: 1
and state laws relating to building construction,and hereby authorize 366 11 050 R-3(Custom)
representatives of this city to enter upon the above mentioned property for
inspection purposes. (We)agree to save indemnify and keep harmle h
City of Cupertino against liabilities,judgments,costs,and p ses which PERMIT EXPIRES IF WORK IS NOT STARTED
may accrue against said City in consequenceIi -th ranting of this it. WITHIN 180 DAYS OF PERMIT ISSUANCE OR
Additionally,the applicant understandis and'will comply wit on-point
source regulations per the CupertthO Municipal C.a-, ection 9.18. 180 DAYS FROM LAST CALLED INSPECTION. I
n
Sinetur-
g ,
Date:09/21/2017
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
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. I
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:9-21-2017
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 1 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
material. Additionally,should I use equipment or devices which emit hazardous I
shall not employ any person in any manner so as to become subject to the 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,Cr,pter9:1 -
exemption,I become subject to the Worker's Compensation provisions of the the Health&Safety Code,Sections 25505 ,and 255 ',
Labor Code,I must forthwith comply with such provisions or this permit shall %}
be deemed revoked. Owner or authorized agen
APPLICANT CERTIFICATION
Date:9-21-2017 �,
I 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 hereb irm that there is a cdnstruction lending agency for the performance ,
relating to building construction,and hereby authorize representatives of this city62.-o w r's for which this permit i$issued(Sec.3097,Civ C.)
to enter upon the above mentioned property for inspection purposes. (We)agle Lender's Name { I,
to save indemnify and keep harmless the City of Cupertino against liabilities,
judgments,costs,and expenses which may accrue against sa' 6ify in'—'�-� Lender's Address
II
consequence of the granting of this permit. Addi LonathrtFe ap I' • understands I
ARCHITECT'S DECLARATION
and will comply with all non point sce regulations pe 19 upertino Municipal
Code,Section 9.18. I understand my plans shall be used as public records.
I
Licensed
Signa r• ' Date 9-21-2017 Professional .