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B-2016-2270CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: CONTRACTOR: PERMIT NO: B-2016-2270 21103 TAMARIND CT CUPERTINO, CA 95014-1638 (326 08 016) JONATHAN WEI CHIH SU CUPERTINO, CA 95014 OWNER'S NAME: PANDEYANAND KAND POONAM DATE ISSUED: 07/07/2016 OWNER'S PHONE: 408-718-1718 PHONE NO: (408) 255-8999 LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: License Class GENERAL BUILDING CONTRACTOR Lie. #681633 Contractor JONATHAN WEI CHIH SU Date 12/31/2017 X BLDG X_ ELECT _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: NEW TEMPORARY POWER POLE (100 AMPS); OLE/ABOVE I hereby affirm under penalty of perjury one of the following two declarations: GROUND 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. 2 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 Sq. Ft Floor Area: Valuation: $200.00 permit is issued. APPLICANT CERTIFICATION 1 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 Number: 32608 Occupancy Type: and state laws relating to building construction, and hereby authorize 326 016 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 ISNOT 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 Cupertino Municipal Code, Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION. Signature C--''� 1 Date 7/7/2016 Issued by: Abby yendc Date: 07/07/2016 tOiYA �L OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for one of the RE -ROOFS: All roofs shall be inspected prior to any roofing material being installed. If a roof is following two reasons: 1. I, as owner of the property, or my employees with wages as their sole installed without first obtaining an inspection, I agree to r ove 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) z. 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: 7/7/2016 I hereby affirm under penalty of perjury one.of the following three declarations: ALL ROOF COVERINGS TO BE CLASS " " OR BETTER 1. 1 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 D UR 2. I have and will maintain Worker's Compensation Insurance, as provided for by I have read the hazardous materials requirements u der 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 stoa or handle hazardous s. 1 certify that in the performance of the work for which this permit is issued, I material. Additionally, should I use equipment or deli es 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 Quali ty Management District I Worker's Compensation laws of California. If, after making this certificate of will maintain compliance with the Cupertino Municip Code, Chapter 9.12 and exemption, I become subject to the Worker's Compensation provisions of the the Health & Safety Code, Sections 25505, V 533, and 25534. Labor Code, I must forthwith comply with such provisions or this permit shall be deemed revoked. ; Owner or authorized agent: APPLICANT CERTIFICATIONDate: 7/7/2016 CONSTRUCTION`l LENDING N Y 1 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 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, 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 ARCBITE T' DE LA N and will comply with all non -point source regulations per the Cupertino Municipal or I understand my plans shall be used as public records. Code, Section 9.18. Licensed Signature Date 7/7/2016 professional GENERAL PERMIT APPLICATION 1AEP COMMUNITY DEVELOPMENT DEPARTMENT m BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 lyeApIlk (408) 777-3228 • FAX (408) 777-3333 • bui(ding2cupertino.org �(; CUPERTINOLJ1b `� Ej PLUMBING ❑ MECHANICAL l_J ELECTRICAL n MISCELLANEOUS Z - PROJECT ADDRESS � 0 � V l � C.�V�•�� }`L� C�� `U�'`lr��N �v APN it ��� " ��" ®�V . OWNHRNAN(I? tl6 G,inrf.(Je. _...._ + PIIOVP.�f,8'�P$, —11�'Ny( J; -MAIL STREIi`C ADDRESS? (7 i ( o / CITS Sl:\'ll;. /.IP e_ / 2� l I FAX v CONTACT NAME ""t✓' J PHONE F(�.: t 1G 'J V J [ E-MAIL STREET ADDRESS WCO tt V\ Ne- 7`1 CITY, STATE_, ZIP 'i1�C� CA qSN FAX El OWNER.. ❑. OWNE,R-BUILDE..R ❑ OWNER AGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHJIF.0"r ❑ ENGINFFR ❑ DF.VE OPER ❑ 'TENANT CONTRACTOR NAME16,Xk \, J I rJ V LICE NS} N MBL:R-&S162 7 L[CENSI; TYPE BIiS.I.IC ri72 �} ` COMPANY NAME H COMPANY q�f�� f , E-MAIL - FAX STREET ADDRESS , ® 94— Au -e--- CITY, STATE, ZIP l J 7 f� � PHONE /L y� ARCHITECT/ENGINEER NAME t(i%� / I LICI.NSI: AliMBi R � � © (31IS. 1.Ic # t v -{ ®� � �{ l� COMPANY NAMr;'1 _ p�I — 7 �:ul I-1'1A1L FAX STR[ I I ADDRESS C'11`Y SI'AIl"ZIP PHONE USE OF V. orDUPL]EX ❑ MULTI -FAMILY BUILDING: ❑ COMMERC]AL PROJECT INWILDLAND ❑ YES URBAN INTERFACE AREA ❑. NO PROJECT IN ❑ YES FLOOD ZONE ❑ NO IS THE BLDG A EICHLER.HOME? " ❑ YFs ❑ NO DESCRIPTION OF WORK too `(�p� ,. 5 TOTAL VALUATION: IVED BY: =111-ICE 13y my signature bC10W, I ccrtily to each of the following: I am the property ownchor authorized agcnt to act on the property o "ner s behalf. I have application and the information I have provided is correct. I have read the Descr6tion of Work and verity it is accurate. I agree to comply with all applicable ordinances and state laws relating to buildmg-co'ttrult . . authorize representatives of Cupertino to enter the above-identifi d property for inspection Signature of Applicant/Agent: �% Date: _ 0 read this local purposes. SUPPLEMENTAL INFORMATION REQUIRED O rfcLuS ; ONLY ` r U G' V a 0 OVEI -Tx -c6uNTER EXPRESS ❑ STANDARD El LARGE nxA.r�R �W)"PiWiscApp 2011.doc revised 06/21/11