B-2016-3127 i
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2016-3127
7406 RAINBOW DR CUPERTINO,CA 95014-5331(366 19 017) RAYNE PLUMBING&
SEWER SERVICE INC
SAN JOSE,CA 95112
OWNER'S NAME: NELSON KENNETH N TRUSTEE DATE ISSUED:11/15/2016
OWNER'S PHONE:408-727-3021 PHONE NO:(408)283-0600
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO;
License Class C36 Lic.#447221
Contractor RAYNE PLUMBING&SEWER SERVICE INC Date 10/31/2017 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:'
CLEANOUT-PROPERTY LINE
I hereby affirm under penalty of perjury one of the following two declarations:
i. 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
lir .e..rmance 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:$3800.00
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 366 19 017
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 regulati, per the Cu ertino, unicipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
Signaturel (1 lial Date 11/15/2016 Issued by:Kim Dunbar
Date: 11/15/2016
OWNER-BUILDER DECLARATION
BE-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 ro
owner installed without first obtaining an inspection,I agree to remove all new materials for
1. I,as 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 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:11/15/2016
I hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
i. 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 HAZARDOUS MATERIALS DISCLOSURE
performance of the work for which this permit is issued.
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
maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
permit is issued. Health&Safety Code,Section 25532(a)should I store or handle hazardous
s. 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
Worker's Compensation laws of California. If,after making this certificate of will maintain compliance with the Cupertino M ,'copal Code,Chapter 9.12 and
exemption,I become subject to the Worker's Compensation provisions of the the Health&Safety C.if,S 'ons 45 s ,25533, fid 25534.
Labor Code,I must forthwith comply with such provisions or this permit shall \ 4
be deemed revoked. -Owner or authorized agent: k it 1111_,...
APPLICANT CERTIFICATION Date:11/15/2016
CONSTRUCTION LENDING AGEN
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 understands ARCHITECT'S DECLARATION
and will comply with all non-point source regulations per the Cupertino Municipal I understand my plans shall be used as public records.
Code,Section 9.18.
Licensed
Signature Date 11/15/2016 Professional
GENERAL PERMIT APPLICATION MEP {i
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
1./9,,,, 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 I's/I 'S C
CUPERTINO (408)777-3228•FAX(408)777-3333•buildincaa,cupertino.orq
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LUMBING_ ❑MECHANICAL ❑ELECTRICAL El MISCELLANEOUS
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PROJECT ADDRESS l/l ice' 6 ka.i .ht..),,,,) p. ). APN# � re 1
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❑OWNER 0 OWNER-BUILDER EkWNER AGENT 0 CONTRACTOR 0 CONTRACTOR AGENT 0 ARCHITECT ❑ENGINEER 0 DEVELOPER 0 TENANT
CT R N E g; LICENSE.NUMBER q `ti 2. 1 LICENSE TYPEC,3c BUS.LIC# 07g LI
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COMPANY NAME (( i E-MAIL FAX
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ARCHITECT/ENGINEERNAME LICENSE NUMBER BUS.LIC# e
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COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF 0 SFD or DUPLEXIP/MULTI-FAMILY PROJECT IN WILDLAND 0 YES PROJECT IN ❑YES IS THE BLDG AN ❑YES
BUILDING:
0 COMMERCIAL URBAN INTERFACE AREA 0 NO _FLOOD ZONE 0 NO EICHLER HOME? 0 NO
. DESCRIPTION OF WORK E 1\
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TOTAL VALUATION: 3 0
By my signature below,I certify to each of e following: ere property owner or authorized agent to act on the property owner's behalf. I have read this
application and the information I have prfoyi•-d cor,ee.t. e read the Desc.ption of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating to buil I. • trq''an..�ii thorize repress •tives of Cupertino to enter the above-identified property for inspection purposes.
Signature of Applicant/Agent:\"U f
Date:
SU'PLEMENTAL INFORMATION IRED bi iCE E ONLY., ,
A,W Q'OVER-TBE-COIF TER
El'1EXPRESS.,
:N 0 €STANDARD
0.LARGE
0 MAXOR -
MEPMiscApp_2011.doc revised 06/21/11
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