B-2016-3291 CITY OF CUPERTINO BUILDING'P RMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2016-3291
908 BROOKGROVE LN CUPERTINO,CA 95014-4668(375 39 037) DAVILA PLUMBIN
COMPANY INC
SAN JOSE,CA 95151
OWNER'S NAME: GAO GE AND MAO HONGYANG DATE ISSUED:12/19/2016
OWNER'S PHONE:408-204-5879 PHONE NO:(408)449-0030
LICENSED CONTRACTOR'S DECLARATION BUILDING PE' I INFO:
License Class C-36 Lic.#934263
Contractor DAVILA PLUMBING COMPANY INC Date 02/28/2018 X BLDG —ELECI X PLUMB
I hereby affirm that I am licensed under the provisions of Chapter 9(commencing —MECH X RES I 1 ENTIAL—COMMERCIAL
with Section 7000)of Division 3 of the Business&Professions Code and that my
license is in full force and effect. JOB DESCRIPTI I N:
PROPERTY LINE I LEAN OUT-SEWER
I hereby affirm under penalty of perjury one of the following two declarations:
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
4'1FA -`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:$3800.00
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 APN Number: Occupancy Type:
and state laws relating to building construction,and hereby authorize 375 39 037
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 E I 'IRES IF WORK IS NOT STARTED
may accrue againstsaidCity in stands and e othe hg this permit.
intWITHIN 18 ii 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 F I'OM LAST CALLED INSPECTION.
.10
Signature 1 I Date 12/19/2016 Issued by:Abby Ay.nde
Date:12/19/2016
OWNER-BUILDER 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 ins.-cted prior to any roofmg 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•'taming 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)
2. 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:12/19/2016
I hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
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. H' RDOUS MATERIALS DISCLOSURE
2. I have and will maintain Worker's Compensation Insurance,as provided for by I have read the haz rdous 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. I will
permit is issued. maintain compliance 'th 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 C de,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. Additionall,,should I use equipment or devices which emit hazardous
air contaminants as •fined by the Bay Area Air Quality Management District I
Worker's Compensation laws of California. If,after making this certificate of will maintain compli ce 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. C,Owner or authorize agent:
APPLICANT CERTIFICATION Date:12/19/2016
I certify that I have read this application and state that the above information is C 4 NSTRUCTION LENDING AGENCY
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 work's for which th s 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. I understand my plan.shall be used as public records.
Licensed
Signature Date 12/19/2016
Professional
GENERAL PERMIT APPLICATION MEP
., COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING D VISION
10300 TORRE AVENUE•CUPERTINO,CA 95014-3255
CUPERTIN 3 I (408)777-3228•FAX(408)777-3333•buifdinq(a cupertino.orq MISC
PLUMBING El MECHANICAL ELECTRICAL, MISCELLANEA
PROJECT ADDRESS (O V
13 (245L..
25. rb v e e APN# ,do , J 0 3
OWNER NAME / 6.0 (/
PHONE�� [�' E-MAIL
STREET ADDRESS q g " CITY, STATE,ZIP l FAX,t ; e 1,,, r C , .�e. ;_ a (A 01
CONTACT NAME C e PHONE 110 8®��ti X5 74. E-MAIL
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STREET ADDRESS 10{; Bsro c,r ro ele Lei
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F L re I FAX itiO
WNER ❑ OWNER-BUILDER 0 OWNERAGENT 0 CONTRACTOR 0 CONTRACTOR AGENT 0 CHITECT 0 ENGINEER 0 DEVELOPER 0 TENANT
CONTRACTOR NA,I LICENSE ,aERII
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COMPANY NAME i{ (( E-MAIL _ FAX
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STREET ADDRESS CITY,STATE,ZIP PHONE
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ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC#
COMPANY NAME E-MAIL —���—�—
FAX
STREET ADDRESS CITY,STATE,ZIP
PHONE
USE OF :Ir.SED or DUPLEX 0 MULTI-FAMILY i PROJECT IN WILDLAND 0 YES PROJECT IN 0 YES IS THE BLDG AN lZ YES
BUILDING: COMMERCIAL URBAN INTERFACE AREA EINO FLOOD ZONL r,/
0 IM NO EICHLER HOME? 0 NO
DESCRIPTION OF WORK
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TOTAL VALUATION:
By my signature below,I certify to each of the following: I am the property owner or authorized age .-":rion the property I- . ave rea
application and the information I have provided is correct. I have read the Description of Work and verify it is accurate. I a omply with all applicable local -
ordinances and state laws relating to building cons ction. I authorize representatives of Cupertino to enter the above-identified property for inspection purposes.
Signature of Applicant/Agent: _ 4 Date: },/i g- /i‘
SUPPLEMENTAL INFORMATION REQUIRED OFFICE USE ONLY
0 OVER-ME-COUNTER
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❑ EXPRESS
0 STANDARD
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't ❑ LARGE -
❑ MAJOR
MEPMiscApp_2011.doc revised 06/21/11