11080157 mFMRION 4F 1
CITY OF CUPERTINO BUILDING PEIZMI
lI
GATE
BUILDING ADDRESS: 19752 BIXBY DR CONTRACTOR:J13S HOMES INC PERMIT NO: 11080157
0R'S NAME: SHETYE WAI FUNG AND SANDEEP D 10542 E ESTATES DR DATE ISSUED: 1024/2011
O R'S PHONE: 4085053346 CUPERTINO,CA 95014 PHorve NO:(408)390-5577
LICENSED CONTRACTOR'S DECLARATION
. „ ,,,,,1; ,•, J„,. .. _ .. BUILDING PERMIT INFO: BLDG r ELECT r PLUMB r
Licens,'6,s, p, :G2q Lie'# 2
�2 �57 MECHr RESIDENTIAL T—
COMMERCIALr
Contractor,,._:`-3fGy�V"(S Date
''10'"'II JOB DESCRIPTION:ADD TO EXISTING MASTER BEDROOM&
hereby affirm Thal l am licensed under the provisions of Chapter 9 MASTERBATH(191SQFT)&REMODELING OF SAME(145SQFT)&
(commencing with Section 7000)of Division 3 of the Business&Professions ADD NEW 1/2 BATH INCLUDED IN 191 SQFT,NEW ROOF
Code and that my license is In fall force and effect. 11@2/2011-REV#I-REVISE REAR FACADE EXTEND TO'FWO(2)FT,RELOCATE
FURNACE TO ATTIC-)1220011 REVI ISS'D
I hereby affirm under penalty of perjury one of the following two declarations:
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.
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:$100000
APPLICANT CERTIFICATION
I certify that I have read this Application and state that the above information is APN Number:36909017.00 Occupancy Type:
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 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, PERMIT EXPIRES IF WORT{ IS NOT STARTED
costs,and expenses which may accrue against said City in consequence of the
granting of this permit Additionally,the applicant understands and will comply WITHIN 180 DAYS OF PERMIT ISSUANCE OR
with all non-point source regulations per the Cupertino Municipal Code,Section 180 DAYS FROM LAST CALLED INSPECTION.
9.18.
Si noture�/ _Dater,//.�22.:rL(,,,. Issued by:''d'�"���� Dale:// 2 z
❑ OWNER-RUILDER DECLARATION
1 hereby affirm that I am exempl from the Contractor's License Law for one of RF.-ROOFS:
the following two reasons: All roofs shall be inspected prior to any roofing material beng installed.if a roof is
I,as owner of the property,or my employees with wages as their sole compensation, installed without first obtaining an inspection,I agree to remove all new materials for
will do the work,and the structure is not intended or offered for sale(SecJ044, inspection.
Business&Professions Code)
I,As owner of the property,am exclusively contracting with licensed contractors to Signature of ApplicanC Date:
construct the project(Sce.7044,Business&Professions Code).
1 hereby affirm under penally of perjury one of the following three ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
declarations:
I have and will maintain a Certificate of Consent to self-insure for Worker's HAZARDOUS MATERIALS DISCLOSURE.
Compensation,As provided for by Section 3700 of the Labor Code,for the
1 have read the hazardous materials requirements under Chapter 6.95 of the
performance of the work for which this permit is issued.
I have and will maintain Worker's Compensation Insurance,As provided for by California Health&Safety Code,Sections 25505,25533,and 25534. 1 will maintain
he performance of the work for which this compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
Section 3700 of the Labor Code,for t
P Safely Code,Section 25532(a)should I store or handle hazardous material.
permit is issued. Additionally,should I use equipment or devices which emit hazardous air
I certify that in the performance of die work for which this permit is issued,I shall contaminants as defined by the Bay Area Air Quality Management District I will
not employ any person in any manner so as to become subject to the Worker's maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
Compensation laws of California. If,after making this certificate of exemption,I Ilealth&Safety Code,Sections 25505,25533,and 25534.
become subject to the Worker's Compensation provisions of the Labor Code,I must Owner or euth Z Z r
zedisg/3�.p1:/
forthwith comply with such provisions or this permit shall be deemed revoked. Owner I ./ Dale: //—
liotz
APT I (CANTCERTIFICATION CONSTRUCTION LENDING AGENCY
I certify that I have read this application and state that the above information is
lating I hereby affirm that there is a construction lending agency for the performance ol'sulrk's
correct.I agree to comply with all city and county ordinances and state laws re
to building construction,and hereby authorize representatives of this city to enter for which this permit is issued(Sec.3097,Civ C.)
upon the above mentioned property for inspection purposes.(We)agree to save Lender's Name
nify and keep hamdess the City of Cupertino against liabilities,judgments,
and expenses which may accrue against said City in consequence of the Lender's Address
gl',uting of this permit.Additionally,the applicant understands and will comply
with all non-point source regilbuiuls per rhe Cupertino Municipal Code,Section ARCI I ITECT'S DECLARATION
9.18.
I understmmd my plans shat l be used as public records. '
Signature Dale
Licensed Professional_