B-2017-2003 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2017-2003
6080 WILLOWGROVE LN CUPERTINO,CA 95014-4649(375 38 019) FISHER POWER&
DATA INC
MOUNTAIN VIEW,CA
94043
OWNER'S NAME: DICKINSON JAMES 0 JR AND CHRISTINE J DATE ISSUED: 11/20/2017
OWNER'S PHONE:408-390-9054 PHONE NO:(650)964-1000
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
• License Class C-10 Lic.#606341 X BLDG X ELECT _PLUMB
Contractor FISHER POWER&DATA INC Date 03/31/2019
MECH`XC 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:
PANEL UPGRADE(200 AMPS)-SAME LOCATION
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
)erformance 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. Sq.Ft Floor Area: Valuation:$2800.00
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 38 019
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
sourceregulations per the Cupertino Municipal - action 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
nature Date 11/20/2017 Issued by:AbbyAyende
T Date: 11/20/2017
0 E'-B Vis" ' DE_,A.2.— _O-
I hereby aff m that I am exe 't from the Contractor's License Law for one of the RE-ROOFS:
following •o reasons: All roofs shall be inspected prior to any roofmg material being installed.If a roof is
1. I, '.- 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:11/20/2017
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 Code,Chapter 9.12 and
exemption,I become subject to the Worker's Compensation provisions of the the Health&Safety Code,Sec x,15,25533
Labor Code,I must forthwith comply with such provisions or this permit shall -''
be deemed revoked. G I'wner or authorized ag•-
APPLICANT CERTIFICATION Date:11/20/2017 -
I certify that I have read this application and state that the above information is CO S :ACTION LEND G GENC
correct.I agree to comply with all city and county ordinances and state laws I hereby affirm that there is: construction lendi o• agency for the performance
relating to building construction,and hereby authorize representatives of this city of work's for which this per •'t is issued - . 097,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.
Signature Date 11/20/2017 Licensed
Professional
•
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
:t :'+' 10300 TO•RRE AVENUE • CUPERTINO, CA 95014-3255
xD 20 n— - Zcb3
a�1srt,`, (408)777-3228 • building@cuUertinO.org PEMIT tB-
CUPERTINO REV, DEF,
•
❑ NEW CONSTRUCTION ❑ADDITIONALTERATION ❑Ti. ❑MEP ❑RE-ROOF ❑SWIMMING POOL/SPA
PROF REI®3 J coA( 7r1% 6j�42 . 1.....t..., ]APNA 5,_,V . O\9
OWNER NAME l PHONE [1.CSr.M,p� ICj ni,�E-Jvf�1IL •
•
STREET ADDRESS t' CITY STATE,ZIP '
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CONTRACTOR NJ E DOWNER-BUILDER COMPANY NAME LICENSE NUMBER LICENSE TYPE
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CITY,STATE,
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•
❑ARCHITECT 0 Ow.NER.0 OWNER AGENT 0 CONTRACTOR AGENT 0 ENGINEER 0 DEVELOPER 0 TENANT •
CONTACT NATOtE1 1 !cE-M rL
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STREET ADDRE i k C STATE,ZIP PHONE
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DECRIPTON
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•
SINGLE-FAMILY/DUPLEX ;)0 MULTI-FAMILY 0 INDUSTRIAL 0 COMMERCIAL
EXISTING USE EXISTING SF NEW FLOOR SF PORCH SF DECK SF DEMO SF STORIES a TOTAL NET SF USE TYPE OCC . SQ.FT. VALUATION(5) .I
REMODEL REMODEL KITCHEN REMODEL OTHR GARAGE ❑ATTACHED
BATHROOM 5F - I •SF SF SF 0 DETACHED
FIREtS RINKLERS 0 NO IYE'S EICHLER ❑D YES SECOND STORY ADDITION OYES
NO
DWELLING SECOND DWELLING ❑yas 0 ATTACHED DETACHED OTHER '
UNITS.; UNIT ADDITON: ❑N0 SF
•
POOLS 0 FIBERGLASS 0 VINYL-LINED 0 GUNITE 0 PREFABRICATED
POOL-SF SPA-SF I SPA ATTACHED 1:1 YES 0 NO I TOTAL-SF , _ '
RE LVED BY: VALUATION:
Commercial or Mulli-Family Bvildinss with Public Swinm:ins Pools requires Devo•Imen(of E,,vironlnenlal Heal!,approval �p tifk Q - ITU-AL
7 /n�
•
RE-ROOF EXISTING ROOF TYPE:' ❑BUILT-UP ROOF❑ASPHALT SHINGLES WOOD SHAKES❑WOOD SHINGLES❑T E OTHER(SPECIFII) U'
REMOVE/REPLACE❑NO IF,NO PLYWOOD ❑11'" ❑3/B" • PLYWOOD TYPE: PITCH: ROOF CLASS
DYES t OF LAYERS THICKNESS El 5X OTHER ❑OSB ❑CDX OTHER :12 A
PROPOSED ROOF TYPE:❑BUILT-UP ROOF, ❑ASPHALT SHINGLES ❑WOOD SHAKES OWOOD SHINGLES 0 OTHER
*Provide a,signed copy of the:Cupertino's Tear-Off Policy SF ;of SQUARES
By my signature below I certify 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 the 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 authorize representatives of Cupertino to
enter the above-identified,propert •- .-ispec In purpose ----.sage and authorize all information contained on this application form
to be made available for publ.. ecord.
Signature of,Applicant/Agent: __..1i Date:
_141-=1.17 .•
SUPPLEMENTAL INFORMATION ATION R A UIRED
*New SFD/Second Dwelling Units/NI ,:family Dwellings:A Demolition permit is required prior to issuance of a building permit for all new construction.
*Commercial Buildings: Provide a coma eted Hazardou ' aterials Disclosure form if any Hazardous Materials are being used as part of this project.
*Copy of Planning Approval Letter or Meeting wi 1 lanning prior to submittal of Building Permit application.
"HOA-Provide a letter of approval from the Home Owner's Association
•
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BldgApp_2017.doc revised 08/01/17