B-2016-1200 Signed PermitCITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS:
10827 LINDA VISTA DR CUPERTINO, CA 95014-4748 (356 07 034)
CONTRACTOR:
( SANDIUM INC )
SAN JOSE, CA 95134
PERMIT NO: B-2016-1200
OWNER'S NAME: MARSHALL JOSEPH D AND CHAREAN B TRUSTEE DATE ISSUED: 01/15/2016
OWNER'S PHONE: PHONE NO:
LICENSED CONTRACTOR'S DECLARATION
License Class Lic. #
Contractor ( SANDIUM INC ) Date
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.
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.
2.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.
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 and state laws relating to building construction, and hereby
authorize 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 may accrue against said City in consequence of the
granting of this permit. Additionally, the applicant understands and will
comply with all non-point source regulations per the Cupertino Municipal
Code, Section 9.18.
Signature___________________________________ Date
OWNER - BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor’s License Law for one of the
following two reasons:
1.I, as owner of the property, or my employees with wages as their sole
compensation, will do the work, and the structure is not intended or offered
for sale (Sec.7044, Business & Professions Code)
2.I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec.7044, Business & Professions Code).
I hereby affirm under penalty of perjury one of the following three 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.
2.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.
3.I certify that in the performance of the work for which this permit is issued, I
shall not employ any person in any manner so as to become subject to the
Worker’s Compensation laws of California. If, after making this certificate of
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
be deemed revoked.
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 and state laws
relating to building construction, and hereby authorize 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 may accrue against said City in
consequence of the granting of this permit. Additionally, the applicant
understands and will comply with all non-point source regulations per the
Cupertino Municipal Code, Section 9.18.
Signature___________________________________ Date
BUILDING PERMIT INFO:
X BLDG ELECT PLUMB
X MECH X RESIDENTIAL COMMERCIAL
JOB DESCRIPTION:
INSTALL (N) A/C UNIT IN SIDE YARD AREA
Sq. Ft Floor Area: Valuation: $10000.00
APN Number:
356 07 034
Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
Issued by: 1445
Date:
RE-ROOFS:
All roofs shall be inspected prior to any roofing material being installed. If a roof is
installed without first obtaining an inspection, I agree to remove all new materials for
inspection.
Signature of Applicant:_______________________________
Date:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
HAZARDOUS MATERIALS DISCLOSURE
I have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533, and 25534. I will
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
Health & Safety Code, Section 25532(a) should I store or handle hazardous
material. Additionally, should I use equipment or devices which emit hazardous
air contaminants as defined by the Bay Area Air Quality Management District I
will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and
the Health & Safety Code, Sections 25505, 25533, and 25534.
Owner or authorized agent: ________________________________
Date:
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance
of work's for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
Lender's Address
ARCHITECT’S DECLARATION
I understand my plans shall be used as public records.
Licensed
Professional________________________________________________
CITY OF CUPERTINO BUILDING PERMIT
BUH.DINGADDRESS:
CONTRACTOR:
PERMIT NO: B-2016-1200
10827 LINDA VISTA DR CUPERTINO, CA 95014-4748 (356 07 034)
(SANDIUM INC)
SAN JOSE, CA 95134
OWNER'S NAME:
DATE ISSUED: 01/15/2016
OWNER'S PHONE:
PHONE NO:
LICENSED
BUILDING PERMIT INFO:
License Class Lic. # C20 893)J11
Contractor (SANDIUM INC) Date < (5 /Zvi
X BLDG ELECT PLUMB
_ _X
MECH X RESIDENTIAL COMMERCIAL
I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing
with Section 1000) of Division 3 of the Business & Professions Code and that my
license is in full force and effect.
JOB DESCRIPTION:
INSTALL (N) A/C UNIT IN SIDE YARD AREA
I hereby affirm under penalty of perjury one of the following two declarations:
r. 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.
r. 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
Sq. Ft Floor Area:
Valuation: $10000.00
this permit 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
APN Number;
Occupancy Type:
ordinances and state laws relating to building construction, and hereby
35607 034
authorize 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
PERMIT EXPIRES IF WORK IS NOT STARTED
expenses which may accrue against said City in consequence of the
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
granting of this permit. Additionally, the applicant understands and will
comply with all non -point source regulations per the Cupertino Municipal
180 DAYS FROM LAST ED INSPECTION.
Code, Section 9.18.
'—
Signature Date j `l,t�(/Zv(•&
I su '1 5 s
Date: /
OWNER -BUILDER DECLARATION
RE -ROOFS:
I hereby affirm that I am exempt from the Contractor's License Law for one of the
All roofs shall be inspected prior to any roofing material being installed. If a roof is
following two reasons:
installed without first obtaining an inspection, I agree to remove all new materials for
r. I, m owner of the property, or my employees with wages as their sole
inspection,
compensation, will do the work, and the structure is not intended or offered
for sale (Sec.7044, Business & Professions Cade)
Signature of Applicant:
z. I, as owner of the property, am exclusively contracting with licensed
Date:
contractors to construct the project (Scc.7044, Business & Professions Code).
I hereby affirm under penalty of perjury one of the following three declarations:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
r.. I have and will maintain a Certificate of Consent to self-i_n_snre for W rtz_�ker's
Compensation, as provided for by Section 3700 of the Labor Code, for the
HAZARDOUS MATERIALS DISCLOSURE
performance of the work for which this permit is issued.
I have read the hazardous materials requirements under Chapter 6.95 of the
z. 1 have and will maintain Worker's Compensation Insurance, as provided for
California Health & Safety Code, Sections 25505, 25533, and 25534. I will
by Section 3700 of the Labor Code, for the performance of the work for which
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
this permit is issued.
Health & Safety Code, Section 25532(a) should I store or handle hazardous
3 I certify that in the performance of the work for which this permit is issued, I
material, Additionally, should I use equipment or devices which emit hazardous
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
will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and
Worker's Compensation laws of California. If, after making this certificate of
the health & Safety Code, Sections 25505, 25533, and 25534.
exemption, I become subject to the Worker's Compensation provisions of the
Labor Cade, I must forthwith comply with such provisions or this permit shall
Owner or a t5horized agent:�/� �—
be deemed revoked.
Date: t� l� 12,016
APPLICANT CERTIFICATION
CONSTRUCTION LENDING AGENCY
I certify that I have read this application and state that the above information is
I hereby affirm that there is a construction lending agency for the performance
correct. I agree to comply with all city and county ordinances and state laws
of work's for which this permit is issued (Sec. 3097, Civ C.)
relating to building construction, and hereby authorize representatives of this city
Lender's Name
to enter upon the above mentioned property for inspection purposes. (We) agree
to save Indemnify and keep harmless the City of Cupertino against liabilities,
Lender's Address
judgments, costs, and expenses which may accrue against said City in
consequence of the granting of this permit. Additionally, the applicant
ARCHPrFCT'S DECLARATION
understands and will comply with all non -point source regulations per the
I understand my plans shall be used as public records.
Cupertino Municipal Cade, Section 9.18.
Licensed
Professional
Signature Date