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B-2016-1358 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2016-1358 22101 LINDY LN CUPERTINO,CA 95014-4836(356 25 018) (WATER SYSTEMS PLUMBING) SAN JOSE,CA 95136 OWNER'S NAME: DALLE ORE LUCIANO V AND CRISTINA M DATE ISSUED:02/12/2016 OWNER'S PHONE:408-317-8507 PHONE NO:408-266-8222 LICENSED CONTRACTOR'S DECcrLARATION BUILDING PERMIT INFO: License Class Lia Contractor(WATER SYSTEMS PLUMBING)Date 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: RE-PIPE ENTIRE WATER LINE TO COPPER;CHANGE 3 SHOWER I hereby affirm under penalty of perjury one of the following two declarations: VALVES 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. 0 I have and will maintain Worker's Compensation Insurance,as provided for v 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 information is correct. I agree to comply with all city and county - APN Number: Occupancy Type: ordinances and state laws relating to building construction,and hereby 35625 018 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 PERMIT EXPIRES IF WORK IS NOT STARTED expenses which may accrue.against said City in consequence of the WITHIN 180 DAYS OF PERMIT ISSUANCE OR granting of this permit. Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal 180 DAYS FROM LAST CALLED INSPECTION.. Code,Section 9.18. 01 Issued by:Phuong Devries Signature c Date " '� Date: 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) Signature of Applicant: 2. I,as owner of the property,am exclusively contracting with licensed Date: contractors to construct the project(Sec.7044,Business&Professions Code). I hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER s, 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 .HAZARDOUS MATERIALS DISCLOSURE performance of the work for which this permit is issued. I have read the hazardous materials requirements under Chapter 6.95 of the z I have and will maintain Worker's Compensation Insurance,as provided for California Health&Safety Code,Sections 25505,25533,and 25534. I will by Section 3700 of the Labor Code,for the performance of the work for which maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the this permit is issued. Health&Safety Code,Section 25532(a)should I store or handle hazardous s. 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 will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and Worker's Compensation laws of California.. If,after making this certificate of the Health&Safety Code,Sections 25505,25533,and 25534. 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 Owner or authorized agent: be deemed revoked. Date: i 2–)'6 APPLICANT CERTIFICATION 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 ARCHITECT'S DECLARATION I understand my plans shall be used as public records. understands and will comply with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. Licensed Professional Signature Date GENERAL PERMIT APPLICATION 'MEP COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO,CA 95044-3255 (408)777-3228•FAX(408)777-3333•buifding(U-)cupertino.org CUPERTINO MISC �J PLUMBING ❑MECHANICAL []ELECTRICAL ❑MICELLANEOUS PROJECT ADDRESS 2- 1 0 i r� ` / APN# OWNER NAME L� �' PHONE E-MAIL. ei �1 � _t( ore_ ?11-7 r, 0 STREET ADDRESS CITY,/STATE,ZIP FAX CONTACT NAME -- PHONE E-MAIL STREET ADDRESS n r r }? / i J CI3 S E,ZI S C e-p� g r 1 3 6 FAX V 1 OWNER El OWNER-BUILDER ❑ OWNER AGENT ❑ CONTRACTOR 1:1CONTRACTOR AGENT ElARCHITECT ElENGINEER ElDEVELOPER ElTEN9b2 el -7 ANT CONTRACTOR NAME rn� jj,, LICENSE NUMBER LICENSE TYPE BUS.LIC n COMPANY'NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP i PHONE ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC# COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE USE OF ❑SFD or DUPLEX ❑ MULTI-FAMILY PROJECT IN 7;tLAND ❑ YES PROJECT IN ❑YES IS THE BLDG AN ❑YES BUILDING: ❑CONSTERCIAL URBAN INTERFACE AREA. ❑ NO FLOOD ZONE ❑NO EICHLERHOME? ❑ NO DESCRIPTION OF WORK t R f t' rA 0,tvt fn p°!iS w14vt 3 C- �� I L TOTAL VALUATION: /'I/ RECEIVED B u By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on the pr e o per'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 property for inspection purposes. Signature of Applicant/Agent: , Date: SUPPLEMENTAL INFORNrATibN REQUIRED - X x�� © SS�A'DARDs y URGE A7EPMiscApp_2011.doc remised 06121/11