11100078 (2) CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10365 CALVERT DR CON'I'RACfoR:CWBUILDERS PERMITNO: 11100078
OWNER'S NAME:: FAI DANIEL JOHN ET AL PO BOX 3206 DATE ISSUED: 12/12/2011
NER's PRo;ve: 4088889938
SARATOGA, CA 95070 PHONE NO:(408)378.4323
I7 /
LICENSED CON'IRI2
ACI.O 'S DECLARATION
v BUILDING 1'Ii12p1I'f INFO: RLDC F— F.Lh:C'I'r PLUMB
License Class Lie.4 \IBCII RhSIDF,N'1'IAL CONINIh:RCLV.
Contractor DatC
JOBDESCRIPTION: SfDWL DD:MO(I pJ95Ql'I')
1 hereby affirm that I am licensed under the provisions of Chapter 9
(commencing with Sector,70fo)of Division 3 of the Business& Professions
Code and that my license is in full force and effect.
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 Valuation:$2000
performance of the work for which this permit is issued. Sy.FI Floor Arca:
I have and will maintain Worker's Compensation Insurance,its provided for by
Section 3700 of the Labor Code,for the performance of the work for which this APN Number:37517025.00 Occupancy Type
permit is issued.
\PPI IC\N'F CERTIFIC.\TION
1 certify that I have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED
correct. I agree to comply with all city and county ordinances and state laws relating WITHIN 180 DAYS OF PERMIT ISSUANCE OR
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save 180 DAYS FROM LAST CALLED INSPECTION.
indemnify and keep harmless the City of Cupertino against liabilitics,judgments,
costs,and expenses which may accrue against said City in consequence of the Date:
granting of this permit. Additionally,the applicant understands and will comply Issued by;
with all non-poinl s ur a guhuions per the Cupertino Municipal Code,Section
9.18.
Z �2 RF: :
Signator Dale _� All roofs shall be inspected prior to nn-v mouoingtingmaterial being installed. If a roof is
Installed without fust obtaining an inspection,I agree to remove all new materials for
inspection.
DWNER-Bl11LD1iR DECLARATION Date:hereby affirm that I oat exempt from the Contractor's License Law for one of Signature ol'Applicane_
the following two reasons: AL1.ROOF COVERINGSTO BE CLASS"A"OR[IF l-fF.l2
I,as owner of the property,or my employees with wages as their sole compensation,
will do the work,mid the structure is not intended or offered for sale(Sec.7044,
Business&Professions Code)
IIA%Al2DOlIS MATERI\1 S DISCI,OSURI•;
I,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business&Professions Code). I hove read the hazardous materials requirements under Chapter(.95 of the
California Ibulth&Safety Code,Sections 25505,25533,and 25534. [will
1 hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
declarations: RcaIIII&Safety Code,Section 25532(a)should I store or handle hazardous
I have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally,should 1 use equipment or devices which emit hazardous
Compensation,as provided for by Section 3700 of the Labor Code,for the air contaminants as defined by the Bay Area Air Quality Management District I
performance of the work for which this permit is issued. will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and
the Ilcallh&Safely Code,Section AS lMS3,and 25534.
1 have and will maintain Worker's Compensation Insurance,as provided for by j /Z/f
Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized ages Dale:
permit is issued.
I certify that in the performance of the work for which this permit is issued,I shall
not employ any person in any manner seas to become subject to the Worker's LONS"IRl'CI'ION 1 F-LADING AGh:NCA'
Compensation laws of California. 11',after making this certificate of exemption,I
become subject to the Worker's Compensation provisions of the labor Code,I must I hereby affirm that there is a construction lendingCiv C.)agency for the performance of
forthwith comply with such provisions or this permit shall be deemwork's or which this permit is issued(See.3097,ed revoked. Lender's Name_
APPLICANT CERTIFICATION Lender's Address_
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 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 ARCIIITFCES DECLARATION
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
osis,and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records.
tinting of this permit.Additionally,the applicant understands and will comply
ith all non-point source regulations per the Cupertino Municipal Code,Section Licensed Professional_
9.18.
Date
Signature