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B-2017-1687 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2017-1687 10785 BROOKWELL DR CUPERTINO,CA 95014-4608(369 21 014) MOOMAU PLUMBING SAN JOSE,CA 95118 OWNER'S NAME: ARMSTRONG RICK D AND WENDY B TRUSTEE DATE ISSUED:09/28/2017 . OWNER'S PHONE:650-576-2241 PHONE NO:(408)396-3837 LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: License Class C36 Lic.#792821 Contractor MOOMAU PLUMBING Date 08/31/2018 X BLDG _ELECT X PLUMB I hereby affirm that I am licensed under the provisions of Chapter 9(commencing _ MECH X RESIDENTIAL_COMMERCIAL with Section 7000)of Division 3 of the Business&Professions Code and that my license is in full force and effect. JOB DESCRIPTION: (N)470 GAL WATER HEATER -SAME LOCATION I hereby affirm under penalty of perjury one of the following two declarations: 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. I have and will maintain Worker's Compensation Insurance,as provided for by ov)f Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. Sq.Ft Floor Area: Valuation:$1982.00 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 369 21 014 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 ser the Cupertino Municipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION. 'fi Signature ��w a 0 Date 9-28-2017 Issued by:Kim Dunbar Date:09/28/2017 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. 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:9-28-2017 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. 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 Co.• • tions 25505,25533,and 25534. Labor Code,I must forthwith comply with such provisions or this permit shall , J be deemed revoked. Owner or authorized agen s f= �� 6 APPLICANT CERTIFICATION Date:9-28-2017 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 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. I understand my plans shall be used as public records. Licensed Signature Date 9-28-2017 Professional *V‘51� :GENERAL PERMIT A;PPLJCAT O - . t COMMUNITY;DEVELOPMENT'DEPARTMENT BUILDING DIVISION ` 1'0300 TORRE AVENUE CUPERTINO,CA 95014-3255 (408)777-3228•;FAX,(408)777-3333:buildinqAeupertino.orq V PLUMBING''. ` 0MECrooKwoiHAINTICAL nw ,., ❑ELECTRICAL ,„”"❑MISCELLANEOUS , ,PROJECT ADDRESS .4PN�' ,„3t,„9 ,,:, : , , ,. .., . .. .. . OWNER NAME _ ' gg �" - PHONE' E-MAIL° . , , . ,,g STREETADDRESS° ST 'E l AX" & CONTACT'NAME PHONE E-MAIL r tc�e. Y �S 'C �i l -121-E1 . STREET,ADDRES,S Q1(1�' F--[) I r 10 T k 1 F .. n � V - 0.OWNER' ' ❑ OWNER-BUILDER. ❑'OWNER AGENT' `.CONTRACTOR- 0 CONTRACTOR AGENT 0 ARCHITECT ❑,.ENGINEER. ,0 DEVELOPER -❑TENANT CONTRACTOR NAME I ob LICENSENUMBER /A / UU��I LICE\SE.TYPE/' BUS L1C �� COMPANYN4ME &,h L "�r�b (\J Lila flQOmau Pt '�b� ��n�' 1► P, C co ,4t,. ,,-�' 2�3-��I „ ` STERE ADDRESS - � T E;Z P 1 I Ul .� ,`fit`; C;69 q 1.1 b)7%3 -I'lll�1' ARCHITECT/ENGINEERNAME` " LICENSE NUMBER BUS.LIC;S ' . g C,OIMIPANY NAME „ - - . E-MAIL 1 AX a ST,REE'FADDRESS ' CITY,STATE,ZIP PHONE USE OP •.. 'SF))or Duplex ,❑'•Multi-Family. PROJECT IN WILDLAND' • PROJEGI IN STRUCTURE::i' ❑.,CoilltilCiClal. :. URBANINTERFACE'AREA 0 Yes ❑ No ,' .PLOOD'ZONE 'CI'Yes 0 No DESCRIPTION OF 41,ORK" I�• I ,` ( I (Ooj - or\ -,. .:. . ., ., . ., , , :,, TOTAL VALUATION:' t.„.„,,,°® Y, ,..,, , ,, .Fl�-„:.,,,,,,,,„ ,„„„4,,,:,,,..,,,„ �' �f �.r . ,, , , a t>�� .I i _ , 3 I By 14,signature below,I certify to each of the following: I`am'ahe;propeity"owner or authejied'agent to`act on"the property owner's behalf. Ihave-read this" • - • • apphcation'and the infonnation`I have pr.vided is coirect. I'have"read the Description of-Work and veiify it is+accurate.I ab ee'to comply with all applicable local ' a ordinances•and state laws relating ,' • g"cousin ctil •r `representatives of Cupertino to,enter'the-abdve-ic•n I p 4.C. "fo inspection purposes. VA Signature:ofApphcantfAgent: _�� Date (—�j` 1p1 S PPLEMENTAL INFORMATION REQUIRED ," iti t.k 1 :OFrICE'USE oNLY,, ; , ' ,11:1','SOV CR TriLr COUNTCR " ❑ EX•PRCss . 0 STANDARD ' �' „ „ " , „", s',,,,-,,•-' t . s 1,A11,GD c ,. . ❑. i5AQrg. - . ' . .. - " . MEPMiscApp_201.1:ddc'revised,O3/16/1`1,