B-2019-0738 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2019-0738
20200 LUCILLE AVE APT 10 CUPERTINO,CA 95014-2042(316 02 094)20200 MIRANDA
LUCILLE AVE APT 11 CUPERTINO,CA 95014-2042(316 02 094)120200 LUCILLE ELECTRICAL SERVICE
AVE APT 16 CUPERTINO,CA 95014-2043(316 02 094)20200 LUCILLE AVE APT 15 INC
CUPERTINO,CA 95014-2042(316 02 094)120200 LUCILLE AVE APT 14 CUPERTINO, SAN JOSE,CA 95127
CA 95014-2042(316 02 094)120200 LUCILLE AVE APT 13 CUPERTINO,CA 95014-
2042(316 02 094)120200 LUCILLE AVE APT 12 CUPERTINO,CA 95014-2042(316 02
094)120200 LUCILLE AVE APT 9 CUPERTINO,CA 95014-2042(316 02 094)
OWNER'S NAME: DATE ISSUED:05/16/2019
OWN
ER'S PHONE: PHONE NO:(408)829-5863
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class C-10 Lic.#860767 X BLDG X ELECT —PLUMB
Contractor MIRANDA ELECTRICAL SERVICE INC Date 06/30/2019 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:
VERANDAS-BUILDING 7 UNITS 9-16-PANEL UPGRADE(400
I hereby affirm under penalty of perjury one of the following two declarations: AMP)SAME LOCATION;TRENCHING ON PRIVATE PROPERTY
1. I have and will maintain a certificate of consent to self-insure for Worker's MASTER PLAN-B-2018-1406
Compensation,as provided for by Section 3700 of the Labor Code,for the
performance 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:$10000.00
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above APN Number: Occupancy Type:
information is correct.I agree to comply with ail city and county ordinances 31602094
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 SIF WORK IS NOT STARTED
City of Cupertino against liabilities,Judgments,costs,and expenses whichPERMIT EXPIRE
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 FROM LAST CALLED INSPECTION.
Signature Date 05/16/2019 Issued by:Jasmine Archbold
9
Date:05/16/2019
OWNER-BUILDER DECLARATION
RE-ROOFS:
I hereby affirm that I am exempt from the Contractor's License Law for one of the All roofs shall be inspected prior to any roofing material being installed.If a roof is
following two reasons: installed without first obtaining an inspection,I agree to remove all new materials for
1. I,as owner of the property,or my employees with wages as their sole inspection.
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 Signature of Applicant:
contractors to construct the project(Sec.7044,Business&Professions Code). Date:05/16/2019
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
I nts under Chapter 6.95 of the
2. I have and will maintain Worker's Compensation Insurance,as provided for by have read the hazardous materials requireme
California Health&Safety Code,Sections 25505,25533,and 25534. I will
Section 3700 of the Labor Code,for the performance of the work for which this
maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
permit is issued. Health&Safety Code,Section 25532(x)should I store or handle hazardous
3. I certify that in the performance of the work for which this permit is issued,I material. Additionally,should I use equipment or devices which emit hazardous
shall not employ any person in any manner so as to become subject to the 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,Sections 25505,25533,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:05/16/2019
CONSTRUCTION LENDING AGENCY
certify that I have read this application and state that the above information is I hereby affirm that there is a construction lending agency for the performance
correct.I agree to comply with all city and county ordinances and state laws of work's for which this permit is issued(Sec.3097,Civ C.)
relating to building construction,and hereby authorize representatives of this city Lender's Name
to enter upon the above mentioned property for inspection purposes. (We)agree
to save indemnify and keep harmless the City of Cupertino against liabilities, Lender's Address
judgments,costs,and expenses which may accrue against said City in
consequence of the granting of this permit. Additionally,the applicant understands ARCHITECT'S DECLARATION
and will comply with all non-point source regulations per the Cupertino Municipal I understand my plans shall be used as public records.
o e,Section .