B-2016-3133 i
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CITY OF CUPERTINO BUILDING PERMIT j
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2016-3133
10434 SCENIC CT CUPERTINO,CA 95014-2765(357 07 019) CUPERTINO
PLUMBING INC
SAN JOSE,CA 95124
OWNER'S NAME: BAUTISTA DONALD J AND ALICE M TRUSTEE DATE ISSUED:111/16/2016
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OWNER'S PHONE:408-255-0826 PHONE NO:(408)253-0618
LICENSED CONTRACTOR'S DECLARATION _ BUILDING PERMIT INFO:
License Class PLUMBING Lic.#624905
Contractor CUPERTINO PLUMBING INC Date 04/30/2018 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:
NEW 3/4 GALVANIZE GAS LINE TO FIRE PLACE
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
'
performance of the work for which this permit is issued.
/--2/7
2.ZI have and will maintain Worker's Compensation Insurance,as provided for by l
At. Section 3700 of the Labor Code,for the performance of the work for which this
kT permit is issued. Sq.Ft Floor Area: Valuation:$1000100
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 357 07 019
representatives of this city to enter upon the above mentioned property for i
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
source regulations per the Cupertino Municipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
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/�. �-'
Signature sf% `'
/ Date 11/16/2016 Issued by:AbbyAyende
r.- Date: 11/16/2016
OWNER-BUILDER DECLAMATION
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:11/16/2016
I hereby affirm under penalty of perjury one of the following three declarations:
ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
i. 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
maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
permit is issued.
3. I certify that in the performance of the work for which this permit is issued,I Health 8z 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,Sections 25505,25533,and 25534.
Labor Code,I must forthwith comply with such provisions or this permit shall :f
be deemed revoked. Cl// e� "f
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APPLICANT CERTIFICATION /Owner or authorized ager Date:11/16/2016 ' '
I certify that I have read this application and state that the above information is CONSTRUCTION LENDING AGE' CN Y
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
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 I
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.
- Code,Section 9.18.
Licensed
Signature Date 11/16/2016 Professional
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GENERAL PERMIT APPLICATION. MEP
.1kr , COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
s 10300 TORRE AVENUE•CUPERTINO,CA 95014-3255 misc
(408)777-3228• FAX(408)777-3333• building icupertino.orq
CUPERTINO
LUMBING []MECHANICAL
❑ELECTRICAL ❑MISCELLANEOUS
PROJECT ADDRESS 462 d' (—ft APN 3 51 O� 0
OWNER NAME 134 LP Vs PHOT 5_57_0
✓ 0 72/°�y E-MAIL.
STREET ADDRESS CITY STATE,ZIP e" FAX
CONTACT NAME / F ( and PI 3- ,a y • E-MAIL
�►� N/LJ l!. �Cjl
STREET ADDRESS CITY,STATE,ZIP FAX
❑"OWNER 0 OWNER-BUILDER 0 OWNER AGENT 0 CONTRACTOR 0 CONTRACTOR AGENT 0 ARCHITECT 0 ENGINEER 0 DEVELOPER 0 TENANT
CONTRACTOR NAME r
C� r I
LSUE
ab I LICENSE TYPEaI_+� BUS.LIC 5 V I
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COMPANY NAME � E-MAIL FAX
ciper-Ivo
1'10 of
STREET ADDRESS CITY,STATE ZIP P NE
COM etv•e_
ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC#
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF i sFD or DUPLEX 0 MULTI-FAMILY- PROJECT IN WILDLAND 0 YES PROJECT IN 0 YES IS THE BLDG AN 0 YES
BUILDING: 0 COMMERCIAL URBAN INTERFACE AREA ❑ NO FLOOD ZONE. 0 NO 1 EICHLER HOME? 0 NO
DESCRIPTION OF WORK r
!rte`��///fry if a S �i td r j4
TOTAL VALUATION: VUv RECEIVED BY
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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 baalf. 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 authori_-representatives of Cupertino to enter the above-identified property for inspection purposes.
Signature of Applicant/Agent: Date: /17-/#6 /`6'
EMENTAL INFORMATION REQUIRED n;
OFEICE'iTSE OI`'LI �.>.,r
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0 OVER,T'HE COUI\TER
0 EXPRESS
uta D STANDARD
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�c 0 LARGE a
a 0 TIAIOR
MEPMiscApp_201I.doc revised 06/21/11