12050113 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10271 MIRA VISTA RD CONTRACTOR:FAST WA'II:R I II'A'ITR PERMIT NO: 12050113
OWNER'S NAME: BASSR'I'T W ILLIAM 11 AND'TONI 13 12601 132 AVE NE DA'I'S ISSULD:05/1 120 1 2
OWNER'S PHONE: 4084823028 KIRKLAND,WA 98034 1'110X4:NO:1800X54.8955
❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT r PLUMB r
License Class Lic.U r r r
\IFCII RF:SIDEN'f1AL CONI\IFRCLU,
Contractor Datc
1 hereby affirm that 1 am licensed under the provisions of Chapter 9 JOB DESCRIPTION: RI:NIOV19RI:['].ACI:GAS WAII.R I ll:A'IIiR
(commencing with Section 7000)of Division 3 of the Business&Professions
Code and that my license is in full force and effect.
hereby affirm under penalty of perjury one of the following two declarations:
I have and will maintain a certificate all consent to self-insure Ibt Worker's
Compensation,as provided for by Section 3700 of the Labor Code.for the
perfiirmanee of Elie work for which this permit is issued. Sq. Ft Floor Area:0 Valuation:51625
I have and will maintain Worker's Compensation Insurance;as provided for by
Section 3700 oflhc labor Code,for the performance of the work for which this
permit is issued. APP'Number:35702035,00 Occupancy'I ype:
AI'1'LI(:ANT CERI'IF'IC TION
I certify that I have read this application and state that the above information is
correct. I agree m comply with all city and county ordinances and state laws relating PERMIT EXPIRES IF WORK IS NOT STARTED
h>huilding construction,and hereby authorize representatives of this city to enter
Upon iheabovc mentioned properly for inspection purposes. (We)agree to save WITHIN 180 DAYS OF PERMIT ISSUANCE OR
indermiHNand keep harmless the City of Cupertino against liabilities,judgments, 180 DAYS FROM LAST CALLED INSPECTION.
costs,and expenses which may accrue against said City in consequence ol'thc
granting of this permit. Additionally.the applicant understands and will comply
with all non-point Source regulations per the Cupertino Municipal Code,Section Issued by: Dae:
9.18,
Signature Bate
RE-ROOFS:
❑ OWNER-BUILDER DF.CLARA PION All roofs shall be inspected prior In any tooling material being installed. II'a roof is
installed without f first obtaining an inspection. I agree In remove all new materials lilt
hereby affirm that I am exempt from the Contractor's License lase for one of inspection.
the fullowing two reasons:
I,as owner of the property,or my employees with wages as their sole compensation. Signature of Applicant Date
will do the work,and the structure is not intended or offered for sale(Sec.7044,
Business&Professions Code)
h as owner of the properly,run exclusively contracting with licensed contractors to AL1,ROOF COVERINGS TO BE CLASS"A"OR BE 1-1 ER
construct the project(Sec.7044,Business&Professions Code).
I hereby affirm under penalty of perjury one of the following three 11,\%:\RDOUS..\IA'I'P:RI,\I,S UISCLOSURF.
declarations: I have read the hazardous materials requirements under Chapter 6.95 of the
I have and will maintain a Certificate of Consent to self-insure for Worker's California Health&Safety Code.Sections 25505,25533.and 25534. 1 will maintain
Compensation,as provided for by Section 3700 of the Labor Code,for the Compliance with the Cupertino Municipal Code.Chapter 9.12 and the I Iealth&
performance oflhe work for which this permit is issued. Safety Cade.Section 25532(a)should I store or handle hazardous material.
I have and will maintain Worker's Compensation Insurance,as provided I'or by Addition:dly,should I use equipment or devices which emit hazardous air
Section 3700 0l the labor Code,for the performance ol'the work for which this contaminants as defined by the Bav Area Air Qualih'Management District I will
maintain compliance with the Cupertino?lunicipal Code,Chapter 9.1_and the
permit is issued. Ile:dth&Safety Code.Sections 25505,25533,and 25534.
1 certify that in the performance of the workfor which this permit is issued.I shall
not employ any person in any manner so as to become subject to the Worker's Owner or authorized agent:
Compensation Imus of California. If,after making this certificate of esemption.I Date:
become subject to the Worker's Compensation provisions of the Labor Code.I must
timhwith comply with such provisions or this permit shall be deemed revoked CUNS'IRUC'I'ION LENDING:\C.F:N(:\'
I hereby affirm thin there is a construeion lending agency lir the per orniance of work's
APPLICANT CERTIFICATION for which this permit is issued(Sec.3097.Civ C.)
I certify that I have read this application and stale that the above information is Lender's Name
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 Lender's Address
upon the above mentioned property for inspection purposes.(We)agree to save
indemnity and keep harmless the City of Cupertino against liabilities,judgments, \RCI II'f E(:'1'S DF:CL:\R:\'PION
costs.and expenses which may acme against said City in consequence of the
granting of this permit.Additionally,the applicant understands and will comply I Understand nw pians shall be used as public records-
with all non-point source regulations per the Cupenino Municipal Code.Section
9.18. Licensed Professional
Signature Date