B-2017-1135CITY OF CUPERTINO BUILDING PERMIT I
BUILDING ADDRESS:
6057 SHADYGROVE DR CUPERTINO, CA 95014-4644 (375 40 005)
OWNER'S NAME: SONG ALBERT
OWNER'S PHONE: 408-777-3228
LICENSED CONTRACTOR'S DECLARATION
License Class B Lic. #425222
Contractor THE SANDMAN TERMITE COMPANY Date 07/31/2018
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.
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
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 oft ranting of this permit.
Additionally, the applicant understands and will ly with all non -point
source regulations per the Cupertino Munipipa C de, Section 9.18.
Date 07-14-2017
I hereby affirm that I am exempt from the Contractor's License Law for one of the
following two reasons:
1. 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)
2. 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:
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
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 making 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.
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 07-14-2017
CONTRACTOR: PERMIT NO: B-2017-1135
THE SANDMAN
TERMITE COMPANY
SAN JOSE, CA 95125.
DATE ISSUED: 07/14/2017
NO: (408) 265-7400
BUILDING PERNUT INFO:
X BLDG X ELECT _ PLUMB
_ NIECH X RESIDENTIAL _ COMMERCIAL
JOB DESCRIPTION:
TEMP POWER POLE (200 AMP)
Sq. Ft Floor Area: I Valuation: $0.00
APN Number: Occupancy Type:
37540 005
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
Issued by: Kim Dunbar
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 ofAppl.
Date: 07-14-2017
ALL ROOF COVERINGS TO BE CLASS "A"
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 Quality Management District I
will maintain compliance with the Cupertino Municipal Cod apter 9.12 and
the Health & Safety Code, Sections 25505, 25 n 25534.
Owner or authorized agent:
Date: 07-14-2017
CONSTRUCTIONLENDINEN Y
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 DECLARATION
I understand my plans shall be used as public records.
Licensed
GENERAL PERMIT APPLICATIONmv==P
COMMUNITY DEVELOPI-\AENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
t (408) 777-3228 • FAX (408) 777-3333 • buildino(cDcupetno.org misc
❑PLUMBING ❑MECHANICAL /ELECTRICAL L G❑l,4ISCELLANTEOUS
PP.OJECT ADDRESS/r I .APN -3 tfo — 00-5
IL
R
OWNER NAME ti&n-7
STREET.ADDRESS � /j% j � /I%� CITY, STATE, �/J / �)� /�/ y , FAX
CONTACT NAME PHONE
STREET ADDRESS !• � / J
CITY, ST.9yE, �) Oro
F. Y
❑ OV�TTER - ❑ mk NER-BUILDER ❑ OR'NER AGENT CONTRACTOR ❑ C�0?.rrRACTOOR AGE\7 ❑ ARCHITECT ❑UtNGIi\`EcR ❑ DEvEI.OPr-Ft ❑ TEA.iNT
CON`!! / n� ,// 1/ - LICE NSENIUI\4BER� � LICE NSE.
B
CO1diPANY NAME E-MAIL
FAX
STREET ADDRESS ��%% �j//•�)' /i����%/ /JITY, STATE; ZIP
(iC/
ARCHITECT/ENGINEER NAME L IICCEENSE NliA4BER
BUS. LIC -,'
CO1vfPANY NAME
E-MAIL
F.AX
STREET ADDRESS
CITY, STATE, ZIP
PHONE
USE OF ❑ SFD or DUPLEX ❑ ATULTI-FAMILY PROJECT IN, lVa DLAN'D ❑ -I-ES PROJECT IN ❑ YES
BUII-DAG: ❑ CmevERCLAL URBAN A'TERFACE AREA ❑ NO FLOOD ZONE ❑ Ivo
IS TIM BLDG AN ❑ 1-zs
EICHLER HOME? ❑ NO
DESCRIPTION OF \FORK � /y7 � / • �� �� � '
a
TOTAL VALUATION: RE E B7 t
By my signature below, I certif� to each of the following: 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 correct. I have read thjq Description of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating to building construction. I au orize presentatives of Cupertino to enter the above -identified prwoperty for inspection purposes.
Signature of.ApplicanU'Agent: Date: / �7 /{/ /J
SUPPLEMENTAL IN 4ATION REQUIRED
k w,.OFFICE:USE 'N -Yfi tz,
t,x
fl OBER=TIiE-COULTER
J V
J -
a SIA�D RDS
�~ TtA70Rs.
A4EPA1iscApp-2011.doc remised 05/21111