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B-2016-2370 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2016-2370 7603 HOLLANDERRY PL CUPERTINO,CA 95014-5070(362 26 064) THOMAS PLUMBING INC MORGAN HILL,CA 95037 OWNER'S NAME: SAKIMA GLEN N AND MIKA DATE ISSUED:07/25/2016 OWNER'S PHONE:408-307-1696 PHONE NO:(408)778-4340 LICENSED CONIRACTOR'S DECLARATION BUILDING PERMIT INFO: License Class C-36 Lic.#356040 Contractor THOMAS PLUMBING INC Date 12/31/2017 X_BLDG _ELECT X PLUMB _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: I hereby affirm under penalty of perjury:one of the following two declarations: REPLACE SEWER MAIN t, 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. 2f avc 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:$2000.00 APPLICANNT 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 362 26 064 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 understa s and will comply with all non-point source regulation er the Cupe ' o Municipal Code,Section 9.18, 180 DAYS FROM LAST CALLED INSPECTION, i Signature Date 7/25/2016 Issued by:Abby Ayende Date:07/25/2016 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(See.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:7/25/2016 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 ofthe 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(x)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 Cde,Chapter 9.12 and exemption,I become subject to the Worker's Compensation provisions of the the Health&Safety Code,S on 25505,25 and 25534. Labor Code,I must forthwith comply with such provisions or this permit shall be deemed revoked. O.w"ner or authorized agent: APPLICANT CERTIFICATION `Date:7/25/2016 1 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 7/25/2016 Professional GENERAL PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION MEP 10300 TORRE AVENUE•CUPERTINO,CA 95014-3255 (408)777-3228•FAX(408)777-3333•building(ftupertino.orgMISIC CUPERTINO: PLUMBING ❑MECHANICAL ❑ELECTRICAL ❑MISCELLANEOUS r �� 2 3 PROJECT ADDRESS � r )� APN# 30 ��p f Ij OWNER NAME , -.l V t k PH � 1 g_MAII, r Jp STREET ADDRESS CITY, ATE.,ZIP FAX CONTACT NAME PHONZ. �@ fi E-MAIL STREET ADDRESS ® p CITY,STATE,ZIP 1•� FAy mmul VU Lj ❑OWNER ❑ OWNER-BUII,DER ❑ OWNER AGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT CNT TOR NA J_ 1 LI ENS ER LICENe TYPE BUS. AN � COMPANY NAMEE L ^ e Lre STREET DRESS nee $ E,ZIP C p t ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC# COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE USE OF V/SFD or Duplex ❑ Multi-Family PROJECT IN WILDLAND. PROJECT IN STRUCTURE: ❑ Commercial URBAN INTERFACE AREA ❑ Yes ❑ No FLOOD ZONE ❑ Yes ❑ No DESCRIPTION OF WORK TOTAL VALUATION: �/ REC]<IUEDBY; By my signature below,I certify to each of the following: I am the roperty owner or authorized agent to act on the property owner's behalf. I have read this application and the information I have pr • ed is correct. I hav d the Description of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating to buF cons ction. I orize representatives of Cupertino to ter the above-identified property for inspection purposes. Signature of Applicant/Agent: _Ite: 7,� SUPPL NTAL OI MATION REQUIRED 'OFFICE USE ONLY W.. ;❑+ OYER THE-COUNTER 7% ' ❑ EXPRESS ❑' STANDARD U a MEPMiscApp_2011.doe revised 03/16111 {