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B-2017-0063 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2017-0063 10543 CEDAR TREE CT CUPERTINO,CA 95014-2003(316 34 021) SPEED DRAIN OF JAE E LEE PLUMBING MOUNTAIN HOUSE, CA 95391 OWNER'S NAME: GACKIERE GHISLAIN AND ESTELLE DATE ISSUED:01/11/2017 OWNER'S PHONE:408-874-5877 PHONE NO:(408)378-5309 JJCENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: License Class C-36 Lic.#911337 Contractor SPEED DRAIN OF JAE LEE PLUMBING Date 02/28/2018 X BLDG —ELECT X 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: INSTALL(N)DESIGNATED GAS LINE FROM METER TO(E)FP 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 performance of the work for which this permit is issued. 2. I have and will maintain Worker's Compensation Insurance,as provided for by 'sC Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. Sq.Ft Floor Area: Valuation:$800.00 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 316 34 021 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 FRO LAST CALLED INSPECTION. Si nature', �--� _tiy — g /Y/ � Date 01/11/2017 Issued by:ME :n .`,�" Date:01/11/2017 1 —'"��� —` 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 inspected.rior 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 ob.*...g 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:01/11/2017 I hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF CO RINGS 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. HAZARD•US MATERIALS DISCLOSURE 2. I have and will maintain Worker's Compensation Insurance,as provided for by I have read the hazardou 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&Sof ty Code,Sections 25505,25533,and 25534. I will permit is issued. maintain compliance with he 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,S ction 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,sho Id I use equipment or devices which emit hazardous air contaminants as define. by the Bay Area Air Quality Management District I Worker's Compensation laws of California. If,after making this certificate of will maintain compliance 'th the Cupertino Municipal Code,Chapter 9.12 and exemption,I become subject to the Worker's Compensation provisions of the the Health&Saf:ty 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 age t` _,.,. - APPLICANT CERTIFICATION Date:01/11/2017 I certify that I have read this application and state that the above information is .► 1'UC "�N LENDING AGENCY 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 per it 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 01/11/2017 Professional GENERAL PERMIT APPLICATION MEP ,v COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISIO €.,r 10300 TORRE AVENUE••CUPERTINO, CA 95014-3255 � ,, (408)777-3228• FAX(408)777-3333•INO building�cupsrtino.org M I S r ®1 ❑PLUMBING ❑MECHANICAL ❑ELECTRICAL `MISCELLANEOUS PROJECT ADDRESS/O�-®h 1-0 C� � ,i� � . C (� APN# ec 3 C/ _ D Z_ OWNER NAME ��� `t ICaC o Hyl CI o�C kONE SCHi� 4o ` 674/.. `-. 8/ STREET ADDRESSS / "v` CITY,STATE,ZIP FAX CONTACT NAMES PHONE408 _ 8.3q e64,60 Ci � STREET ADDRESS �;c j S �t 'h. Allo CITY,STAB F,ZIP Y. Vv- C...)0 S"-.4 . FAX "14 ❑OWNER 0 OWNER-BUILDER El OWNER AGENT. NTRACTOR 0 CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER '❑ TENANT CONTRACTOR NAMJ j �� /// ��� LICENSI ,U/7EI�3 7 LICENSFy T?E�, BUS.LIC# y f-s -� / COMPANY N {/Oc.IM ZP -.)ae'Lee P, 14�E ��'47V-O( 2tt1:t CFV Zy — STREET ADDRESS CIT ' E,ZIP 1 pgONE c� City :r. q' 6 C- SC-- C,q- cg-/3z L%o ARCHITECT/ENGINEER NAME I LICENSE NUMBER BUS.LIC# I COMPANY NAME li E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE E OF ❑SFD or DUPLEX ❑ MULTI-FAMILY PROJECT IN WILDLAND 0 YES PROJECT IN ❑YES IS THE BLDG AN 0 YES BUILDING: EI COMMERCIAL URBAN INTERFACE AREA '❑ NO FLOOD ZONE 0 NO EICHLER HOME? 0 NO DESCRIPTION OF WORK i F Y----_f es F moi' of TOTAL VALUATION: I:( 800 /_--."--'`' r By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on the property.'ner' :-.alf. I have read this ._ application and the information I have provided is correct. I have r@pd the Description of Work and verify it is accurate I ay. .comply with all applicable local – - ordinances and state laws relating to building construction. I BI orize representatives of Cupertino to enter the above-identified property for inspection purposes. Signature of Applicant/Agent: Arai /i Date: 0/ — (t)P\ 7 . SUPPLEMENTj. INFORMATION REQUIRED I OFFICE USE ONLY �✓✓ 0 OVER Tint-COUNTER © EXPRESS U © STANDARD U © LARGE 1-4 - - ❑ MAJOR MEPMiscApp_201 Ldoc revised 06/21/11