13010111 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS:.20870 PEPPER.TREE LN. - CONTRACTOR:PENNINGTON PERMIT NO:13010111
PLUMBING SERVICE
OWNER'S NAME: MARTEN&CATHY KALISVART 118.E FREMONT AVE DATE ISSUED:01/22/2013
OWNER'S PHONE: 4082573206 SUNNYVALE,CA 94087 PHONE NO:(408)738-8115
❑ LICENSED CONTRACTORS DECLARATION JOB DESCRIPTION: RESIDENTIAL U COMMERCIAL
License Class -79 — Lie.# 72 7 q-5- INSTALL PROPERTY LINE CLEAN OUT
�/ �7
Contractor rl1 . - •"�rkkY Date ��
I hereby affirm that 1y1m licensed under a 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:
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. Sq.Ft Floor Ar Valuation:$2000
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 APN3 .00 Occupancy Type:
,& t;s
permit is issued. - - _
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is IT EXPIRES IF WORK IS NOT STARTED
correct.I agree to comply with all city and county ordinances and state laws rela WITHIN 0 DAYS OF PERMIT ISSUANCE OR
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save 180 DAY LAST CALLED INSPECTION.
indemnify and keep harmless the City of Cupertino against liabilities,judgments, 99
costs,and expenses which may accme against said City in consequence of the Issued by: Date: �rr�•�'�
granting of this permit. Additionally,the applicant understands and will comply
with all n so ice regulations:per the.Cupertino Municipal Code,Section
9.18. -
RE-ROOFS:
Signature Date 6 � 22^(7 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.
❑ OWNER-BUILDER DECLARATION
Signature of Applicant: Date:
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER..
1,asownerof the property,or my employees with wages as their sole compensation,
will do the work,and the structure isnot intended or offered for sale(Sec.7044,
Business&.Professions Code)
1,as owner.of the property,am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE;
construct the project(Sec.7044,Business&Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the
California Health&Safety Code,Sections 25505,25533,and 25534. I will-
I hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
declarations: Health&Safety Code,Section 25532(x)should I store or handle hazardous
I have and will maintain aCertificate of Consent to self-insure for Worker's material. Additionally,should I use equipment or devices which emit hazardous
Compensation,as provided for by Section 3700 of the Labor Code,for the air contaminants as defined by the Bay Area Air Quality Management District I
performance of the work for which this permit is issued. will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sections 505, 5533,and 25534.
Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agent: Date:01^22,
permit is issued.
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 CONSTRUCTION LENDING AGENCY -
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 I hereby affirm that there is a concoction lending agency for the performance of
forthwith comply with such provisions or this permit shall be deemed revoked. work's for which this permit is issued(Sec.3097,Civ C.) -
Lender's Name
APPLICANT CERTIFICATION Lender's Address
I certify that I have readthis 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 ARCHITECT'S DECLARATION
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records.
granting of this permit.Additionally,the applicant understands and will comply -with all non-point source regulations per.the Cupertino Municipal Code,Section Licensed Professional - -
9.18.
Signature Date
GENERAL PERMIT APPLICATION M E P
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION \
10300 TORRE AVENUE•CUPERTINO, CA 950143255 (� M I
CUPERTINO (408)777-3228•FAX(408)777-3333•building(a.cuoertino.org �V\
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2pLL1MBING EIMECHANICAL ❑ELECTRICAL ❑iascELLANEGUS
PROTECT ADDRESS 268 0Ln, APN#35cl )3 o5a
OWNERNA"Me-la I ' _ K pl u PHONE �0 257-- Zob -MAIL �—
STREET ADDRESS 2�`,'(Qr•1_A0 1(J `�L � ` CITY, STATE,Z@ ',A� FAX
GG 110/r//y� I y. (�
COMACi NAME
Pon leiYLVL�Ir PHO -fO 2-G. -& Er"U w i '1 `U L91 l—
TRADDRESS �W
❑OWNER ❑ OWNER-BUIDER ❑ OWNER AGENT Nr CONTRACTOR ❑CONTRACTOR AGENT ❑ ARcHITER ❑ENGINEER ❑ DEVELOPER ❑TENANT
CONTRACTORNAME'�,hl, RUVhI LICENSENUMBER -7q2 pp LICENSETYPE t_/ 7Jyb BUS.uc#
COMPANY NAWf5't E-MAILEMASi 1 FAX
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STREETADDRESS Ito �361b rnY,srATE,z� 511vrN cji4 11 PHo KO6 22414 ey
ARCHITECTIENWEER NAME LICENSE NUMBER BUS.WC#
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF ❑SM.,DUPLEX ❑ MULTI-FAMLL.Y PROJECT IN WRDLAND ❑ YES PROJECT IN ❑YES IS THE BLDG AN ❑ YES
BUILDING: ❑COMMERCIAL URBAN INTERFACE AREA ❑ NO FIOODZONE ❑NO EICHLERHOME? ❑NO
DESCRIPTION OF WORK
TOTAL VALUATION: L UU V 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 prop 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. gree to comply with all applicable local
ordinances and state laws relati to building nstnicti authorize representatives of Cupertino m enter the above-identifiedproperty for inspection purposes.
Signature ofApplicant/ e Date-- ^ 22
SUP ME O ON RE.QUMD OFFICE USE ONLY
OVER-THE-COUNTER
❑ EXPRESS
Y
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"� ❑ STANDARD
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❑ LARCE
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❑ MAJOR
MEPMucApp_2011.doc revised 06121111