B-2016-1665CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS:
10310 STERN AVE CUPERTINO, CA 95014-3644 14 033)
CONTRACTOR:
PERMIT NO: B-2016-1665
(375
TITAN GENERAL
CONSTRUCTION INC
FREMONT, CA 94539
OWNER'S NAME: CHAN CONRAD AND TIFFANY WANG
DATE ISSUED: 03/31/2016
OWNER'S PHONE: 650-646-5843
PHONE NO: (408) 883-8668
LICENSED CONTRACTOR'S DECLARATION
BUILDING PERNUT INFO:
License Class B Lie. #948867
Contractor TITAN GEN AI r N TR :C'TIN INCDate 06/30/2016
X BLDG X ELECT _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 ofthe Business & Professions Code and that my
license is in full force and effect.
JOB DESCRIPTION:
I hereby affirm under penalty of perjury one of the following two declarations:
INSTALL TEMP. POWER POLE (100 AMPS)
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
'i performance of the work for which this permit is issued.
1 2. I have and will maintain Worker's Compensation Insurance, as provided for by
t Section 3700 ofthe Labor Code, for the performance ofthe work for which this
permit is issued.
APPLICANT
Sq. Ft Floor Area:
Valuation: $600.00
CER11FICATION
certify that 1 have read this application and state that the above
APN Number:
Occupancy Type:
information is correct. I agree to comply with all city and county ordinances
and state laws relating to building construction, and hereby authorize
375 14 033
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 this permit.
'Additionally, the applicant understands and will comply with all ll non-point
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
source regulations per the Cupertino Municipal Code, Section 9.18.
180 DAYS FROM LAST7C;E D INS CTION.
Signature Date 03/31/2016
—��4 .._.,_
Issued by: ALEX VALLELUNGA
OWNER-BUILDER DER DECLARATION
Date: 03/31/2016
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: 03/31/2016
I hereby affirm under penalty of perjury one ofthe following three declarations:
1. I have and will maintain a Certificate of Consent to self-insure for Worker's
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
Compensation, as provided for by Section 3700 ofthe Labor Code, for the
performance ofthe 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 ofthe 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
Worker's Compensation laws of California. If, after making this certificate of
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
exemption, I become subject to the Worker's Compensation provisions of the
the Health & Safety Code, Sectitiits-25-505,.. 533, and 25534.
Labor Code, I must forthwith comply with such provisions or this permit shall
be deemed revoked.-��
Owner or authorized agent:
APPLICANT CERTIFICATION
Date: 03/31/2016
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.
Signature Date 03/31/2016
Licensed
Professional
GENERAL PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
CUPERTINO (408) 777-3228 • FAX (408) 777-3333 •_buildingCc)-cupertino.org
MEP
MISC
PROJECT ADDRESS10,410 �- APN # ✓� "jw-vl
OWNER NAME HONE . //ll,
MIZ`tJ"t !D� �'. E-MAIL
STREET ADDRESS CITY, STATE, ZIP FAX
CONTACT NAME PHONE E-MAIL
STREET ADDRESS CITY, STATE, ZIP I FAX
❑ OwNER. ❑ OWNER-BUII.DER
❑ OWNER AGENT
❑ CONTRACTOR ❑ CONTRACTOR AGENT
❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME
J
LICENSE4J4!
LICENSETYP
BUS. LIC
2-
COMPANY NAME
EMAIL yy ]
FAX
STREET ADDRESSn/
— 4226
CITY STATE, ZIP V
PHONE <
ARCHITECT/ENGINEER NAME
LICENSE NUMBER
BUS. LIC #
COMPANY NAME
E-MAIL
FAX
STREET ADDRESS
CITY, STATE, ZIP
PHONE
❑ SFD or DUPLEX
: ❑COMMERCIAL
P
❑ MULTI -FAMILY
PROJECT IN WILDLAND '❑ YES
URBAN INTERFACE AREA ❑ NO
PROJECT IN ❑ YES
FLOOD:ZONE ❑ NO
IS THE BLDG AN
EICHLERHOME?
❑ YES
❑ NO
TION OF WORK
TOTAL VALUATION:
RECEIVED BY �=
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 have provided is correct. I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating to_b,.uirclilig constYUcTrm I authorize representatives of Cupertino to enter the above -identified p opertyor spection purposes.
Signature of Applicant/Agent: " —_ Date: j
SUPPLEMENTAL INFORMATION REQUIRED,
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MEPMiscApp_2011.doc revised 06121111