B-2016-2395 CITY OF CUPERTINO BUILDING PERMIT
BUILDINGADDRESS: CONTRACTOR: PERMIT NO:B-2016-2395
20075 BOLLINGER RD CUPERTINO,CA 95014-4532(369 34 003) ECS DESIGN INC
SAN JOSE,CA 95126
OWNER'S NAME: STEWARDS OF THE CHURCH DATE ISSUED:07/27/2016
OWNER'S PHONE:408-838-9156 PHONE NO:(408)971-6695
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO;
License Class ELECTRICAl. Lic.#746472
Contractor ECS DESIGN INC Date 04/30/2018 X BLDG —ELECT _PLUMB
I hereby affirm that I am licensed under the provisions of Chapter 9(commencing X MECH_.RESIDENTIAL X COMMERCIAL
with Section 7000)of Division 3 of the Business&Professions Code and that my
license is in full force and effect. JOB DESCRIPTION:
REPLACE(2)HVAC UNITS-FRONT AND BACK OF BUILDING;
I hereby affirm under penalty of perjury one of the following two declarations: NEW DUCTS-CHURCH OF ASSEMBLY
1. I have and will maintain a certificate of consent to self-insure for Worker's h a„p ,i W
Compensation,as provided for by Section 3700 of the Labor Code,for theK:tG7
performance of the work for which this permit is issued.
/2 Lhave 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:$19000.00
APPLICANT CERTIFICATION
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 34 003
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 per the no Municipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION. ..
G,Signature Date 7/27/2016 Issued by: �Abb AY ende
Dater 07/27/2016
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. I,as owner ofthe property,am exclusively contracting with licensed Signature of Applicant:
contractors to construct the project(Sec.7044,Business&Professions Code). Date:7/27/2016
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
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,Chapter 9.12 and
exemption,I become subject to the Worker's Compensation provisions of the the Health&Safety Code,Sectio 05,25533,and 255
Labor Code,I must forthwith comply with such provisions or this permit shall
be deemed revoked.
L_Owner or authorized agent:
APPLICANT CERTIFICATION Date:7/27/2016
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. 1 understand my plans shall be used as public records.
Signature Date 7/27/2016 Licensed
Professional
GENERAL PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT BUILDING DIVISION MEP
10300 TORRE AVENUE•CUPERTINO,CA 95014-3255
CUPERTIN0 (408)777-3228•FAX(408)777-3333•building(aDcupertino.org MISC
❑PLUMBING , MECHANICAL ELECTRICAL ❑MISCELLANEOUS
(�
PROJECT ADDRESS '0(90 I !�j �1 V IL_ APN# I-) (^ci 34
OC3
OWNER NAME f,i"�Ae&t+ k%EH 6�- L� (j� �((g`/� AI
_ t G(f�� PHONE {V z5b _q1% E-MAIL
STREET ADDRESS 0001.15
0 01 15 M LL 1/I �/) ,()�I CITY,STATE,ZIP r-LA?L� f� \ FAX
CONTACT NAME 1Iv�-1 C I�{(t/l PHONE l V ESL
STREET ADDRESS r Q `7 A t .� S Y CITY,STATE,ZIP FAX
❑OWNER ❑ OWNER-Bu LDER ❑ OWNERAGENT CONTRACTOR ❑CONTRACTOR AGENT v❑ /ARCHITECT ❑` ENGINEER ❑ DEVELOPER ❑TENANT
CONTRACTOR NAME 2cC r) 1,9 LICENSE NUMBER 7,464 LICEJNSEGTYPEI C2� BUS.LIC# 1 ��
COMPANY NAME P r C E-MAIL t ( s((JJ FAX `7
Imo. `77 V V _ eCw
STREET ADDRESS Vd�Zy, � CITY,STAT ,ZIP PHONE ,
ARCHITECT/ENGINEER NAME a '2L(0 LICENSE NUMBER I Cv�
I BUS..LIC#
COMPANY NAME E-MAIL
FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF ❑ SSFD or Duplex _❑ Multi-Family PROJECT IN WILDLAND PROJECT IN
STRUCTURE; `DJ Commercial URBAN INTERFACE AREA ❑ Yes ❑ No FLOOD ZONE ❑ Yes ❑ No
DESCRIPTION OF WORK
TOTAL VALUATION: (q /000 RECEIVEDBY.' a w'
By my signature below,I certify to each of the following: I am the pro owner or authorized agent to act on the property owner's behalf.I have read this
application and the information I have prop�ded is core ct I have readfihe Description of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating t_buflding au e representatives of Cupertino to enter the above-identified p operty for inspection inspection purposes.
Signature of Applicant/Agent. Date: l 2d V
4 SUPPLEMENTAL INtTUTATION REQUIRED ,3-.
J OFFICE-AS>Uny
ca
� OVER�3E-COUN37EI2
;a'E'" � EXPREScS
STANDARD
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D`LARGE
❑` I17AJOR
MEPMiscApp_2011.doc revised 03/16111