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09080389CITY OF CUPERTINO BUILDING PERMIT PERMIT NO: 09080389 CONTRACTOR: NINA ' UTT DATE ISSUED: 08/27/2009 BUILDING ADDRESS: 10657 AMULET PL 106'>7 AMULET PL PHONE NO: OWNER'S NAME: NINA BUTT CU PERTINO CA, 95014-1303 r— ER'S PHONE: 4087365977 ELECT PLUMB BI ILDING PERMIT INFO: BLDG 13 LICENSED CONTRACTOR'S DECLARATION T_ RESIDENTIAL COMMERCIAL MECH License Class Lic. # 1000SQ) Date J()B DESCRIPTION:DEMO POOL &FILL WITH DIRT Contractor rovisions of Chapter 9 I hereby affirm that I am licensed under the p (commencing with Section 7001 of Division 3 of the Business & Professions Code and that my license is in full force and effect. two declarations: I hereby affirm under penalty of perjury one of the following Valuation: $1200 I have and will maintain a certificate of co sent of the Labor Code, for the Sq. Ft Floor Area: Compensation, as provided for by anc Type: rovided for by occupancy yp performance of the work for which this peatiis issued. on Insurance, as p CPN Number: 32643067.00 1 have and will maintain Worker's Comp Section 3700 of the Labor Code, for the performance of the work for which this STARTED permit is issued. IS NOT APPLICANT CERTIFICATION ation is pEgMIT EXPIRES IF WORK IT ISSUANCE OR I certify that I have read this application and state tordin the and staove te laws relating with all city and county WITHIN 180 DAYS OF PERM correct. I agree to comply 180 DAYS FROM LAST CALLED INSPECTION. for inspection Purposes. (We) agree to save to building construction, and hereby authorize representatives (We) city o a enter ` �� ertino against liabilities, judgments, Dat�:l upon the above mentioned property , of the - indemnify and keep harmless the City of Cup in consequence costs, and expenses which may accrue agains;icant understands and will comply Issued b granting of this permit. Additionally, the app with all non -point source regulations per the Cupertino Municipal Code, Section 9.18. s RE: RpOFS DateA*O roofing material being installed. If a roof is Signature All roofs shall be inspected prior to any installed without first obtaining an inspection, I agree to remove all new materials for ' inspection. OWNER -BUILDER DECLARATIONof Date: t from the Contractor's License Law for one Signature of Applicant: I hereby affirm that I am exempt ensatior, the following two reasons: employees "All OR BETTER I, as owner of the property, or my to nt with wages as their sole comp will do the work, and the structure is not intended or offered for sale (Sec.7044, ALL ROOF COVERINGS TO BE CLASS A Business & Professions Code) with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE 1, as owner of the property, am exclusively contracting ter 6.95 of the construct the project (Sec.7044, Business &Professions Code). requir 25533, and 25534. 1 will maintain three I have read the hazardous materials 25505s under Chapter one of the following Code, Chapter 9.12 and the Health & affirm under penalty of perjury California Health e Cupertino Municipal Code, I herebycompliance with the Cup should I store or handle hazardous material. declarations,Safety Code, Section 25532(a) Additionally, should I use equipment or devices which emit gement District I will dous air 1 have and will maintain a Certificate for by Section 3700 of the LaborCode,the Worker's the Bay Area Air Quality Managode, C Compensation, as provided for by contaminants as defined by fiance with the Cupertino Municipal Code, Chapter 9.12 and the performance of the work for which this permit o issued. providedn Insurance, as for by maintain comp Sections Cupertino 25533, and 25534. I have and will maintain Worker's Compee�o�rance of the work for which this Health & Safety Code, Section 3700 of the Labor Code, for the p author gent: b permit is issued. permit is issued, I shall Ow r Date: 1 certify that in the performance of the work for which this r. Worke not employ any person in any manner so as to become subject at the exemption I CONSTRUCTION LENDING AGENCY e�o>mance of work's Compensation laws of California. if, after mon proaking visions of the Labor Code, I r lust agency for the p become subject to the Worker's Comp I hereby affirm that there is a construction 3097 Civ C) g Y l with such provisions or this permit shall be deemed revoked. for which this permit is issued forthwith comply Lender's Name APPLICANT CERTIFICATION bender's Address that I have read this application and state tordinan et the s and stave te laws relating I certify 1 with all city and county to en er TION correct. I agree to comp Y authorize representatives of this city ARCHITECT'S DECLARATION to building construction, and hereby for inspection purposes. (We) agree to sav mer ts, fans shall be used as public records. upon the above mentioned property P Cupertino against liabilities, jo the I understand my p i nify and keep harmless the City of Cup in consequence c,, and expenses which may accrue against said andLice Professional granting of this permit. Additionally, the applicant understands and will comp y with all non -point source regulations per the Cupertino Municipal Code, Secti Dn 9.18. Date Signature v Oct C) g0�5 H CITY OF C UPERTIN O DEMO RM CITY of PERMIT APPL�[CATION FO CUPE�TiNO Date: APN#� Building Address: Mailing Address (if different from building ad f;ss): Owner's Name: Contractor: C�� /9 Contractor icense #- ense Cu ernoBusness Lic ontact: #: Residential R Sq Footage Job Description:19 l Phone: Phone Fax: :11F one: x: Commercial ❑ Sq Footage Valuation: ©c) Project Size: Express ❑ Standard �, Large ❑ Major ❑ P lication Please complete relevant portions of the Green Building Checklist &attach it to the app 'cable include on the plan set & the sheet index. or if applicable, G u permit Type Quantity Fee ID 1DEMORES 1DEMOPRES 1BCBSC / 1BSEISMICRE I F, -.e Description Der,,Io-Residential Pool Demo Residential Cal Bldg Standards Ccmmission Fee Seismic Residential Fee ro p B 1SFDWL-DEM B1SFP00L-DEM B JALL PERMIT TYPES B Revised 01/07/09 1 FA OWNER -BUILDER VERIFICATION (Check one) I or my immediate family (parent, spouse or child) will perform: A % All the work authorized by this permit B _ A portion of the work C _ None of the work If B or C is checked, complete 2 or 3 below. A state licensed contractor will be hired to do: A _ All of the work B _ A portion of the wort; (complete section below) Phone # State License # Type of work to be performed_ 3. — I will utilize unlicensed person(s) ether than my immediate family to perform all or portions of the authorized work. I understand that I maybe an bes be on file at the C ty of oyer (see'reverse side). A Certificate of Insurance covering workers compensation Cupertino Building Department office. Address/City Phone Number Type of work to be Person/Firm performed ..................... . .................................. I declare under penalty of perjury that the alpove is true and correct. I have read and understand the Owner -Builder Information (reverse side). Date: Property Owner's Signature: Job Address: (� Permit # chan es to the information provided on this form shall be submitted to the Ci of Cupertino Build Anv - _----- Department. -- -