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B-2016-1841 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2016-1841 202 CALVERT DR CUPERTINO,CA 95014-3799(375 19 027) GALLAHER COMPANY SAN JOSE,CA 95133 OWNER'S NAME: PATTYO LLC ET AL DATE ISSUED:04/27/2016 OWNER'S PHONE:408-401-4342 PHONE NO:(408)825-1362 LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: License Class PLUMBING Lic.#946359 Contractor GALLAHER COMPANY 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: BLDG#3-WATER HEATER REPLACEMENT 100 GALLONS 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 �Vperformance of the work for which this permit is issued. p 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:$5000.00 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 Number: Occupancy Type: 375 19 027 and state laws relating to building construction,and hereby authorize 375 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 appli ant understands and will comply with all non-point source regulations e the Cupertin Municipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION. /ignature Date 4/27/2016 Issued b :Abb A ende Y YL'— ��""� � Date:04/27/2016 v►�1(N`- 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 prior 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 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:4/27/2016 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 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,S tions 25505,2 /,and 25534. Labor Code,I must forthwith comply with such provisions or this permit shall be deemed revoked. caner or authorized ag AAA APPLICANT CERTIFICATION ate:4/27/2016 I certify that I have read this application and state that the above information is CONSTRUCTION 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 permit 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. 1 understand my plans shall be used as public records. Licensed Signature Date 4/27/2016 Professional GENERAL PERMIT APPLICATION MEP COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION 10300 TORRE AVENUE• CUPERTINO, CA 95014-3255 Cl,1PIERT[Pd0 (408)777-3228- FAX(408)777-3333•building(n,cupertino.or - // PLUMBING MECHANICAL ❑ELECTRICAL ❑MISCELLANEOUS PROJECT ADDRESSO� ` Co 1 l ao APN n �-1� L L op- OWNER NAME Y PHONEq0q i0-LA NZ E-MAIL STREET ADDRES i ,I CITY, STATE,ZIP FAX -7-7 ± o Dr 5 �� J��,�� CP. Gq 51?6 CONTACT NAME PHONEE-MAIL ('Vr cC� �Ue�a �3� 1778 e x,�Gr o ao l Lm-d y-CC i VI STREET ADDRESS CITY,STATE, ZIP FAX la-60-A � � v, 5� cF� �S�33 E] OWNER ElOWNER-BUILDERElOwNERAGENT Ep CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME CEYJ� _NUVrC�i LICENSE NUMBER `� �G LICENSE�Y?P,E� BUS.LIC# r1 4� l CO ErJ "r COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC n COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE USE OF ❑SFD or DUPLEX ❑ MULTI-FAMILY PROJECT IN WILDLAND ❑ YES PROJECT IN ❑ YES IS THE BLDG AN ❑ YES BUILDING: ❑COMMERCIAL URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑NO EICHLER HOME? ❑ NO DESCRIPTION'OF WORK TOTAL VALUATION: 9i i�r1 �> RECEIVED BY By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on the property o ner's behalf. I have read this application and the information I have ovided is co ect..Lhave read the Description of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state]aws relating to b i]d.g_cons c I authorize representatives of Cupertino to enter the above-i ntifi d property for inspection purposes. Signature of Applicant/A � Date: o� SIJ PLEMENTAL INFORMATION REQUIRED oFi ICE USE oi`Li', r.' ❑ ,OVER THE-COUNTER F ; ❑,E PRESS U �' . ' ❑ STANDARD U ❑ LARGE ❑ 11!IAJOR - 5.. MEPAIiscApp_2011.doe revised 06/21111