B-2017-2051 CITY'OF CUPERTINO BUILDING PERMIT
. BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2017-2051
21467 KRZICH PL CUPERTINO,CA 95014-4942(362 05 041) ECONOMY ROOTER
INC
SANTA CLARA,CA
95055
OWNER'S NAME: LEMONS JOHN AND MARY A TRUSTEE DATE ISSUED: 11/30/2017
OWNER'S PHONE:408-725-2523 PHONE NO:(408)249-4922 •
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class C36 Lic.#892045
Contractor ECONOMY ROOTER INC Date 05/31/2018 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:
REPLACE WATER HEATER.5p GAL(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
14) 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
permit is issued. Sq.Ft Floor Area: Valuation:$950.00 _
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 362 05 041
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 s:id City in consequence of the granting of this permit. WITHIN 180 DAYS OF PERMIT ISSUANCE OR
Additionally,the appl',- t understands and will comply with all non-point
source regulations p:"\-/1upertino Municipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
Signature® \ Date 11-30-2017 Issued by:Kim Dunbar
Date: 11/30/2017
• •
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
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. 1,as owner of the property,am exclusively contracting with licensed Signature of Applicant:
contractors to construct the project(Sec.7044,Business&Professions Code). Date:11-30-2017
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 is ay AreaAir Quality Management District I
Worker's Compensation laws of California. If,after making this certificate of will maintain compliance with the'c ertino Municipal Code,Chapter 9.12 and
exemption,I become subject to the Worker's Compensation provisions of the the Health&Safety.Code 1,.\ :tions 255 05,25533,and 25534.
Labor Code,I must forthwith comply with such provisions or this permit shall �\\ 1 1
be deemed revoked. ' 1i�
Owner or authorized agent. , I
APPLICANT CERTIFICATION Date: 11-30-20.17 ••I
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 11-30-2017 Professional
CONSTRUCTION PERMIT APPLICATION
X— '''.' B
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COMMUNITY DEVELOPMENT.DEPARTMENT • BUILDING DIVISION
,.. „A.
i; 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
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�;•a,h.��:, (408) 777-3228 • buil din gGcuvertino.org PEMIT,:B-�l
CUPERTINO REVS DEFE
- ❑ NEW CONSTRUCTION ❑ADDITION ❑ALTERATION ❑T.1. E MEP E RE-ROOF ❑SWIMMING POOL/SPA
PROJECT ADDRESS II APN a
l`I kezick eL 1
OWNER NAME PHONE E-MAIL
M/�-fey . itis gof 70-5--.2-5-.1-3
STREET ADDRESS CILIATE,ZIP
/ -- — — — --:,
❑CONTRACTOR NAME ❑OWNER-BUILDER COMPANY NAME . LICENSE NUMBER LICENSE TYPE
6e u 2 G-E. et rt-A• EC.�r.%.40"N"...-1 14940414 ��t 20 yr
ISTREET ADDRESS CITY,STATE, ZIP
f�- - ics1. e �3�
E-MAIL PHONE BUS.LIC 1
0 ARCHITECT ❑OWNER.❑OWNER AGENT 0 CONTRACTOR AGENT ENGINEER 0 DEVELOPER 0 TENANT
CONTACT NAME E-MAIL
C.±-----.1..)-5 �,..7-1. . •
STREET ADDRESS CITY,STATE,ZIP PHONE
DECRIPTON lig. [A'r-u- 6 -p 1 oil S ` Sl-.--C.-- c 7 t,--
-
•
❑SINGLE-FAMILY/DUPLEX 0 MULTI-FAMILY 0 INDUSTRIAL 0 COMMERCIAL
EXISTING USE EXISTING SF NEW FLOOR SF PORCH SF DECK SF DEMO SF STORIES 9 TOTAL NET SF USE TYPE OCC SQ.FT. VALUATION(5)
REMODEL REMODEL KITCHEN REMODELOTHR ' GARAGE ❑ATTACHED
BATHROOM SF SF SF SF 0 DETACHED
EXISFIREtSPRINKLERS 0 NO NG 1:1 YES
EICHLER 0 NO SECOND STORY ADDITION DYES
NO
DWELLING SECOND DWELLING 0 yes 0 ATTACHED 0 DETACHED OTHER
UNITSI UNITADDITON: ❑NO 5F
POOLS 0 FIBERGLASS 0 VINYL-LINED 0 GUNITE 0 PREFABRICATED
POOL-SF SPA-SF I SPA ATTACHED❑YES 0 NO I TOTAL-SF
RECE] Y:/I TO L VALUATION:
Commercial or Multi-Family Buildings with Public Sminuoiinr Pools reooires Deanrtrncnl of Environmental Heath approval
I // L.V Cro
RE-RD OF EXISTING ROOF TYPE: E BUILT-UP ROOF❑ASPHALT SHINGLES❑WOOD SHAKES D W OD SHINGLEES IDTILE OTHER(SPECIFY)
REMOVE/REPLACE D NO IF NO PLYWOOD ❑1,. D 3/8" ' PLYWOOD TYPE: PITCH: ROOF CLASS
❑YEs ?OF LAYERS THICKNESS❑5/8" OTHER DOSE E CDX OTHER :12 A
PROPOSED ROOF TYPE:❑BUILT-UP ROOF DASPHALT SHINGLES O WOOD SHAKES OWOOD SHINGLES 0 OTHER
*Provide a signed copy of the Cupertino's Tear-Off Policy SF :of SQUARES
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 ave provided is correct. I have read the Description of Work and verify it is accurate. I agree
to comply with all applicable local ordinance ,d state laws relating to building construction. I authorize representatives of Cupertino to
. enter the above-identified property for inspect') ;urposes. I acknowledge and authorize all information c Ztained on this application form
to be made available for public record._
' Signature of Applicant/Agent: "11 Date: it e ° ( 7Z .
SUPPLEMENTAL INFORMATION REQUIRED
*New SFD/Second Dwelling Units/Multifamily Dwellings:A Demolition permit is required prior to issuance of a building permit for all new construction.
*Commercial Buildings: Provide a completed Hazardous Materials Disclosure form if any Hazardous Materials are being used as part of this project.
*Copy of Planning Approval Letter or Meeting with Planning prior to submittal of Building Permit application.
*HOA-Provide a letter of approval from the Home Owner's Association
Bldg.4pp_20)7.doc revised 08.0/7/7