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B-2017-0241CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 22732 MAJESTIC OAK WAY CUPERTINO, CA 95014-5614 (342 32 123) CONTRACTOR: NOAH'S PLUMBING PERMIT NO: -2017-0241 - INC SAN JOSE, CA 95127 OWNER'S NAME: GUSTAFSON KURT E AND LINDA M TRUSTEE DATE ISSUED: 02/09/2017 OWNER'S PHONE: 408-736-5900 PHONE NO: (4081) 592-3821 LICENSED CONTRACTOR'S DECLARATION BUILDING PERMT INFO: License Class (I- 16 Lic. #933252 Contractor NOAH'S PLUMBING INC Date 11130/2017 XBLDG —ELECT X PLUMB I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing —MECH _X RESIDENTL&L — COMMERCIAL with Section 7000) of Division 3 of the Business & Professions Code and that my license is in full force and effect. JOB DESCRIPTION: I hereby a under penalty of perjury one of the following two declarations: (N) 50 GAL WATER HEATER - OUT�IDE CLOSET 1. �4.ff% will maintain a certificate of consent to self -insure for Worker's fa\v\ Join] ompensation, as provided for by Section 3700 of the Labor Code, for the r rfo formance of the work for which this permit is issued. jI 2. 1 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: $406.00 APP LICANT CERTIFICATION I certify that I 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 34232123 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. Additionally, the applicant understands and will comply with ail ll WITHIN 180 DAYS OF PERMIT ISSUANCE OR source reg�iulatio per t -- upertino Municipal Code, Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION. Signature- Date 2/9/2017 Issued by: Abby A_vode OWNER -BUILD dLm Date: 02/092/2017 I hereby affirm that am exempt from the Contractor's License Law for one of the HEAWM: following two reasons: All roofs shall be inspected prior to any roofing material being installed. If roof is 1. 1, 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 on. sale (Sec.7044, Business & Professions Code) 2. L as owner of the property, am exclusively contracting with licensed Signature of Applicant: contractors to construct the project (Sec,7044, Business & Professions Code). Date: 2/9/2017 I hereby affirm under penalty of perjury one of the following three declarations: r. I have and will maintain a Certificate of Consent to self -insure for Worker's ALL ROOF COVERINGS TO BE CLASS "All OR BETTER 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. 1 will permit is issued. maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the 3. 1 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 deflued by the BayArea 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 e ns 25505,25533—a—nd25534. LaboiCode, I must forthwith comply with such provisions or this permit shall be deemed revoked. Owner or authorized agent: PPLICANT CERTIFICATION Date: =017 I certify that I have read this application and state that the above information is CONSTRUCTION LENDING 111wy 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 G.) to enter upon the above mentioned property for inspection purposes. (We) agree Lenclees 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 2/912017 Licensed Professional i GENERAL PERMIT APPLICATION MEP COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 Ci,�PIERT[I�iC) p I ' (408) 777-3228 •FAX (408) 777-3333 • buildina(a�cupertino.or e - LJJ.:Ll:L.ASILLHL LJ rVIIJI.t',LL.'A1V}.vUU,� PROJECTADDRESS 2c17�R i`3 APN#-34Z-- _ IG!J OWNER NAME %/ --Q fi ON's E-1\ZAIL STREET ADDRESS CITY, STATE, ZIP FAX . �J �i!✓ t gGy a �- � ! CONTACT N � � PHONE E STREET ADDRESS �Jj�� ®// CITY, STATE, ZIPy _ FFAX Z ❑ OWNER ❑ OWNER -BUILDER ❑ OWN'ERAGEN�T . ONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑TENANT CONTRA ,R,N'A11 f P LICENSE ��c-j , LIC ' E TI7 E � �j �� BUS. LIC :P — COMPANY NAME p ��` FAX STREET ADDRES/S�/ p � 4g=.0 6 TS G! (��" �� :C CITY; STATE, ZIP G PHONE p d ARCHITECT/ETNGINNEER NAME LICENSE NUA4B R BUS. LIC ft COMPANY NAME E-MAii.—��— '� l 1 FAX STREET ADDRESS CITY; STATE, 'LIP PHONE USE OF ❑ SF.D or DUPLEY ❑ MULTI-FAMII.Y PROJECT INWII.DLAND ❑ YES PROJECT IN - ❑YES ZS THE BLDG AN ❑ YES BUILDING: ©COA9N4ERCLgL URBAN INTERFACE AREA ❑ NO FLOOD ZONE ©NO _ EICHLER HOME? ❑ NO DESCRIPTION OF WORK I I I ! i. I TOTAL VALUATION: �® RECEIVED BY 14 By my signature below, I certify to each of the following. I am the property owner or authorized agent to act on the property owne 's behalf. I have read this application and the information I have pro-, 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 ding struc ' rize representatives of Cupertino to enter the above-iden 'fled pxo rty for inspection.purposes. Signature of Applicant/Agent: - ate: -2- D SUPPLEMENTAL INFO NATION REQUIRED oFFIc> csI ons i aTr ! i� OVER=THE COUNTER .r� E7�I2ES5' �- :❑ LARGE TSAJ072 MEPA1isgApp_2011.doc revised 06121/11