B-2016-2579CITY OF CUPERTINO BUILDING PERMIT
BUILDINGADDRESS: CONTRACTOR: PERMIT NO: B-2016-2579
19479 ROSEMARIE PL CUPERTINO, CA 95014-3452 (375 01 007) OWNER -BUILDER
OWNER'S NAME: COHEN DAVID N ET AL
OWNER'S PHONE: 650-766-9160
LICENSED CONIRACTOR'S DECLARATION
License Class Lie. #
Contractor OWNER -BUILDER Date
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.
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
Performance 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.
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
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 indemnify and keep harmless the
City of Cupertino against liabilities, judgments, costs, and expenses which
may accrue against said City in consequence of the granting of this permit.
Additionally, the applicant understands and will comply with all non -point
source regulations per the Cupertino Municipal Code, Section 9.18.
Signature Date 8-24/2016
I hereby affirm that I am exempt from the Contractor's License Law for one of the
following two reasons:
I, as owner of the property, or my employees with wages as their sole
compensation, will do the work, and the structure is not intended or offered for
sale,(Sec.7044, Business & Professions Code)
I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project(Sec.7044, Business & Professions Code).
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
Compensation, as provided for by Section 3700 of the Labor Code, for the
performance of the work for which this permit is issued.
z. 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.
3. 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 Compensation laws of California. If, after malting this certificate of
exemption, I become subject to the Worker's Compensation provisions of the
Labor Code, I must forthwith comply with such provisions or this permit shall
be deemed revoked.
APWCANT 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 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 indemnify and keep harmless the City of Cupertino against liabilities,
judgments, costs, and expenses which may accrue against said City in
consequence of the gra g of this permit. Additionally, the applicant understands
and will comply with fl on -point source regulations per the Cupertino Municipal
Code, Section 9.1
Signatures Date -8 24/2016
ISSUED: 08/24/2016
PHONE NO:
PERMIT INFO:
BLDG X=ELECT _ PLUMB
ARCH X RESIDENTIAL _ COMMERCIAL
)B DESCRIPTION:
?GRADE PANEL (125 AMPS); SAME LOCATION
Sq. Ft Floor Area: I Valuation: $1565.00
APN Number: Occupancy Type:
375 01 007
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
Issued by: Kim Dunbar
Date: 08/24/2016
RE -ROOFS:
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.
Signature of Applicant:
Date: 8.24/2016
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
HAZARDOUS MATERIALS DISCLOSURE
I have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533, and 25534. I will
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
Health & Safety Code, Section 25532(a) should I store or handle hazardous
material. Additionally, should I use equipment or devices which emit hazardous
air contaminants as defined by the Bay Area Air - uality Management District I
will maintain compliance with the Cupertino cipal Code, Chapter 9.12 and
the Health & SafetyCode, Sec 'o 9 25505, 25533, and 25534.
Owner or authorized agent
Dat_ e: 8-24/2016
CONSTRUCTION LENDING AGENC4'
I hereby affirm that there is a construction lending agency for the performance
of work's for Which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
Lender's Address
ARCHITECT'S DECLARATIOI
understand my plans shall be used as public records.
Licensed
GENERAL PERMIT APPLICATION MEP
COMMUNITY DEVELOPMENT DEPARTMENT - BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228 , FAX (408) 777-3333 • building@cupertino.org
—2Isc 0/ 9
PROJECT ADDRESS 19479 Rosemarie PI, #, Cupertino, CA APN#37.5-01-007
OWNER NAME Cohen David N; Cohen Thelma P PH650-766-9160 E- MA" dc94086Ca)co_ mcast.net..
STREET ADDRESS CITY, STATE, ZIP
460 Fairfax Ave.. San Mateo,. CA 94402 FAX
CONTACT NAME Robert Moore PHONE 408-824-1.11' 6 E-MAIL robert@losnessgroup.com
STREETADDRESS3131 S Bascom Ave., #230 CITY, STATE, ZIP Campbell, CA 95008 1 FAX408-520-4977
❑ OWNER ❑ OWNER -BUILDER e OWNER AGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME Tim Heath LICENSE NUMBER 863821 LICENSE TYPE Elect BUS. LTC #
COMPANY NAME Star Lighting & Electric E-MAIL heath8339gmail.com FAX
STREET ADDRESS 1.800 San Carlos ./{,16 CITY, STATE,ZIP'San Carlos, C 94070 PHONE
ARCHITECT/ENGiNEERNAME l., Ave./"1 7t LICENSE NUMBER ZIP'San l�/'1 7 BUS. LIC#
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY, STATE, ZIP PHONE
l
USE OF - ❑ SFD or DUPLEX IN PVIULTI-FAMSLY PROJECT IN WTLDLAND ❑. YES PROJECT IN ❑ YES IS THE BLDG AN ❑ YES
BUILDING: ❑ COMMERCIAL URBAN INTERFACE AREA Q. NO FLOOD: ZONE ❑D NO EICHLER HOME? NO
DESCRIPTION OF WORK
Install New 125 Amp Main Service to Replace Existing 55 Amp Main Service
Install all new bonding as required by code.
TOTAL VALUATION: $1,565
By my signature below, I certify to each of the followi I am the property owner or authorized agent to act on the property owner's behalf. I have read this
application and the information I have provided is ect. 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 building c rue F I authorize representatives of Cupertino to enter the above--iidentif d rope for inspection purposes.
Signature of Applicant/Agent: Date: f `/,���
AL INFORMATION REQUIRED
IIIEPMiscApp 201L doc revised 06/21/11