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B-2016-3297 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2016-3297 21771 LOMITAAVE CUPERTINO,CA 95014-5925(357 17 101) SILICON VALLEY PLUMBING SAN JOSE,CA 95125 OWNER'S NAME: STILLER RICHARD J AND SUE A TRUSTEE DATE ISSUED:12/19/2016 OWNER'S PHONE:408-252-6825 PRONE NO:(408)292-3975 LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: License Class C36 Lic.#795113 Contractor SILICON VALLEY PLUMBING Date 05/31/2017 X BLDG _ELECT X 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: r" by affirm under penalty of perjury one of the following two declarations: f ' .& I have and will maintain a certificate of consent to self-insure for Worker's Compensation,as provided for by Section 3700 of0 the Labor Code,for the REPLACE MAIN WATER LINE FROM METER TO FOUNDATION performance of the work for which this permit is issued. 2.7-' 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 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 357 17 101 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 applican understands ad will comply with all non-point source regulations pert -Cupertino Arn g.al Code,Section 9.18. 180 DAYS FROM LAST CALLEPECTION. Signature .�'ilL �Er— ---- g J Date 12/19/2016 Issued by:MELISS= S -- OWNER-BUILDERDate: 12/19/2016 DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for one of the RE-ROOTS: 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) • 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. HAZARDOUS MATERIALS DISCLOSURE 2. I have and will maintain Worker's Compensation Insurance,as provided for by I have read the hazardous 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 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 C,,e,Chapter 9.12 and exemption,I become subject to the Worker's Compensation provisions of the the Health&Safety Co ,Section 5505,2559 and 25534. Labor Code,I must forthwith comply with such provisions or this permit shall be deemed revoked. Owner or authorized agent APPLICANT CERTIFICATION Date:12/19/2016 I certify that I have read this application and state that the above information is CONSTRUCTION LENDING AGENC correct.I agree to comply with all city and county ordinances and state laws I hereby affirm that there is a construction lending agency for the performance relating to building construction,and hereby authorize representatives of this city of work's 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. I understand my plans shall be used as public records. Licensed, Signature Date 12/19/2016 Professional , „ GENERAL PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION tI, MEP 10300 TORRE AVENUE•CUPERTINO,CA 95014-3255 (408)777-3228•FAX(408)777-3333•buildings cupertino.orq SIC CUPERTINO .n, PLUMBING I=1 MECHANICAL /� 1=1 ELECTRICAL ID MISCELLANEOUS PROJECT ADDRESS 21 - i'7 1 �®1 19 r A-v it APN# �L r�- — / 9- • " /D / OWNER NAME j �l t ! PHONE ! 7 /E-MAII. it 14 oe- 1-6625 STREET ADDRESS 7 fl `1 Le Iniu. A yT�CSAS C4-1 FAX CONTACT NAME �!�_ l0 3 P I lab 6 F :2–q- 3701 Etimz P742_ 1-- 6 ai-i'itr41\l'.17" STREET ADDRESS ig'7 &44 t St CIT S E Cf._/ ?S 12 FAX ❑OWNER 0 OWNER-BUILDER 0 OWNER AGENT Ft CONTRACTOR 0 CONTRACTOR AGENT 0 ARCHITECT 0 ENGINEER 0 DEVELOPER 0 TENANT CONTRACTOR NAME g L 19 :, / r • LICENSNUMBE LICE]�TSEYP/g_ BUS.LIC# ®� �-L �+ "(� � t � SCJLI COMPANY NAME E-MAIL/]/„/ts; FAX STREET ADDRESS z 7 F�3SAA) e � i CITY,STATE,ZIP 844 �-ex y ?�rl�J HONE)1®B °metz 1�;9 i c ARCHITECT/ENGINEER NAME Aidi-2..LICENSE NUMBER �V/� (/ BUS.LIC# L G COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE USE OF ❑SFD or DUPLEX 0 MULTI-FAMILY PROJECT IN WILDLAND 0 YES PROJECT IN 0 YES IS THE BLDG AN 0 YES BUILDING: 0 COMMERCIAL URBAN INTERFACE AREA Q NO FLOOD ZONE 0 NO EICHLER HOME? 0 NO DESCRIPTION OF WORK4 f f L-A-412. W `Z �3ta..,9,,__ aa. ...., i p fi r-voucil Apo`Pa C& TOTAL VALUATION. `P_ '- LLL '.7• .r BY: By my signature below,I certify to each of the following: I am th-property owner or authorized agent to act on the. .._ . ,.er's behalf. I have read this application and the information I have provided's correct. I have ead the Description of Work and verify it is accurate-I agr-e to comply with all applicable local ordinances and state laws relating'. . ding c k struction. I au rize representatives of Cupertino to enter the above-i 1 enttii.-, property for inspection purposes. Signature of Applicant/Agent: 1 Date: 2- I C „- SUPPLEMENTAL SUPPLEMENTAL INFO• TION REQUIRED OFFICE USE ONLY -- 0 OVER-TILE-COUNTER frza F' ❑ EXPRESS u i 0 STANDARD iJ- . ❑ LARGE a ❑'MAJOR ME'MiscApp_2011.doc revised 06/21/11