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B-2016-2324 CITY OF CUPERTINO BUILDING PERMIT BUILDINGADDRESS: CONTRACTOR: PERMIT NO:B-2016-2324 10645 CORDOVA RD CUPERTINO,CA 95014-3911(342 22 110) KELLY CONSTRUCTION INC MOUNTAIN VIEW,CA 94040 OWNER'S NAME: O'GRADY BRIAN J DATE ISSUED:07/15/2016 OWNER'S PHONE:650-968-9612 PHONE NO:(650)965-9052 LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: License Class$ Lic.#633307 Contractor KELLY CONSTRUCTION INC Date 04/30/2018 X BLDG X ELECT _PLUMB I hereby affirm.that I am licensed under the provisions of Chapter 9(commencing _MECH X RESIDENTIAL_COMMERCIAL 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 AMP'S) I hereby affirm under penalty of perjury one of the following two declarations: 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. z. 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:$700.00 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 342 22 110 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 Cupertino Municipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION. Signatur L !� Date 07/15/2016 Issued by:PAUL O'SULLIVAN Date:07/15/2016 OVVN -BUH DER 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 1. 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) 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:07/15/2016 I hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER r. 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 z. I have and will maintain Worker's Compensation Insurance,as provided for by I have read the hazardous materials requirements under Chapter 6.95of 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 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 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,Sections 25505,25533,and 25534. Labor Code,I must forthwith comply with such provisions or this permit shall be deemed revoked. Owner or authorized ag{e : ;� ,_�� ",z) APPLICANT CERTIFICATION Date:_07/15/2016 N R T N ' A /� certify that I have read this application and state that the above information is `-Lm correct.I agree to comply with all city and county ordinances and state laws I hereby affirm that th re is a construction lending agency for the performance relating to building construction,and hereby authorize representatives of this city of works 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 07/15/2016 Licensed Professional 710 GENERAL PERMIT APPLICATION WCOMIUUNITY DEVELOPI,/1ENT DEPARTMENT• BUILDING DIVISION MEP 10300 TORRE AVENUE• CUPERTINO,CA 95014-3255 GUPERTtNO (408)777-3228 • FAX(408)777-3333• buiidina(d)cuDertino.ont MISC ❑PLUAIMING ❑jbfiECFLkNlCAL ❑ELECTRICAL ❑MISCELLANTEOUS PROTECT?DDRESSl f� T / d•,lC�g&,1114 �� O \ERNAAE SCJ I PH01 Eli II STREETADDRESS4553 1 � I CITY,STA ,ZI q qC6Vkx CONTACT NA.h1E PHO\,*E Y f l�YJ /L 540-7 L �'f�I GIG /IL �G S• �Y STR E.ADDRESS ITY, STE ZIP FAX C� bIU C e ❑ OWINIR El El Ot OWMER-BUILDER WERAGE?T )KCO TRACTOR ❑CONTRACTORAGE-NT 111ARCHITECT 11M,1GL\= 11DE\LLOPER ❑ TENANT CO'.NTRACTOP N.4-1,0±�;/ LICENSE NTI,IBER � � LICENSE TIKE I BUS.LIC e CO1 P.4\TY N,SI,i EI,1AIL ` FAX /lam STREET.ADDP.ESS� � � t CITY;S't.-.TE'IPJ� � ",R CHITECT,T�GINEERNA\1E LICENSE NU IBER BUS.LIC-# COAIPAW. N.kME E-NLAIL FAX STREET ADDRESS CITY,STATE,ZIP I PHONE USE OF ,�-,Lo,DLTPLEX ❑ mmTI-FAMILY. PROJECT L\A'ILDLAOND ❑ 1'ES PROJECT IN ❑ YES Is THE.BLDG:AN ❑%TS BLaDNIG: ❑COMMERCIAL LRB.A ATERFACE AREA �•NO FLOOD ZONE NO EICHLERHOME? NO DESCRIPTION OF)WORT / TOTAL VALUATION. RECFI\ED Bl E ms. i By my signaLare below,I certify to each of the following: I am the property owner or authorized agent to act on the property owners behalf. I have read this application and the infonnation I have provided is correct. I have read the Description of Work and vent,it is accurate. I agree to comply with all applicable local Ordinances and state laws relating to bui ding construction. I au e re-res tatives of Cupertino to enter the above-identified property for inspection purposes. 5ignzture ofAnplicant'Agent: 9 _ _ Date: S PLEMENTAL INFORA1ATION REQUIRED �,yy� M 1 O\'ER TrIE OOuz � ❑ E}.PRESS �* , � U r ' z © L RGENEW � ❑ A1.470R � ., , EP:A/isC,4Pp_?011.docrevised 06121111