12060112 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10325 STONYDALE DR CONTRACTOR:CUPERTINO PLUMBING PERMIT NO: 12060112
OWNER'SNAMF-: WRIGIff WHITELAW AND BARBARA H 1300 DELL AVE.STE C DATE ISSUED:06/192012
OWNER'S PHONE: 4087326483 CAMPBELL.C\ 95008 PRONENO:(408)253-0618
❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT r PLUMB r
License Class Lic.q
MECH r RESIDENTIAL r COMMERCIAL r
Contractor Dale
1 hereby affirm that I am licensed under the provisions of Chapter JOB DESCRIPTION:COZ'I'ER REPIPE
(commencing with Section 7000)of Division 3 of the Business&Professions
Code and that my license is in full force and effect.
I hereby af0rm tinder penally of perjury one of the following two declarations:
I have and will maintain a cerbfica(e of consent to self-insure for Worker's
Compensation,as provided for by Section 3700 of the Labor Code,for the
performance of(he work for which this permit is issued- All
I have and will maintain Worker's Compensation Insurance,as provided for by Sq.FI Floor Area:0 \'alualion,$5000
Section 3700 of the Labor Code,for the performance of the work for which thisR'
permit is issued. APN Number:32637012.00
.Aceupanc},Typc:
,
APPLICANT CERTIFICATION X. �"•:}f
I certify that I have read(his application and slate 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 PERMIT EXPIRES IF WO ISjNOTSTARTED
upon the above mentioned property for inspection purposes. (We)agree to save WITHIN 180 DAYS OF PERMIT ISSUANCE OR
indemnify and keep harmless the City of Cupertino against liabilities,judgments. ]g0 DAYS FROM LAST CALLED INSPECTION.
costs,and expenses which may accrue against said City in consequence of the iC:.�
granting of this permit. Additionally,the applicant understands and will comply �7^' :`•
with all non-point Source regulations per the Cupertino Municipal Code,Section Issued by: `l Date:
9.18_
Signature Dale
:-RF:ROOFS:
❑
OWNER-BUILDER DECLARATION All roofs shall be inspected prior to any roofing material being installed.If a roof is
installed without first obtaining an inspection,I agree to remove all new materials for
I hereby affirm that 1 am exempt from the Contractor's License Law for one of inspection
the following 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,mid the structure is not intended or offered for sale(Sec.7044,
Business&Professions Code)
I,as owner of the property,am exclusively contracting with licensed contractors(o ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
construct the project(Sec.7044,Business&Professions Code).
I hereby affirm under penalty of perjury one of the following three HAZARDOUS MATERIALS DISCLOSURE
declarations: 1 have read the hazardous materials requirements under Chapter 6.95 of the
I have and will maintain a Cerlilicate of Consent io self-insure for Worker's California Health&Safely Code,Sections 25505,25533,and 25534. 1 will maintain
Compensation,as provided for by Section 3700 of(he Labor Code,for the compliance with the Cupertino Municipal Code,Chapter 9.12 and the Ilealth&
performance of the work 1'mr which this permit is issued. Safety Code,Section 25532(x)should I store or handle hazardous material.
I have and will maintain Worker's Compensation Insurance,as provided for by Additionally,should I use equipment or devices which emit hazardous air
Section 3700 of the Labor Code,for the performance of the work for which this contaminants as defined by the Buy Area Air Quality Management District 1 will
permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
I certify That in the performance of the work for which This permit is issued.I shall Ilealth&Safety Code.Sections 25505,25533"and 25534.
not employ any person in any manner so as to become subject to the Worker's Owner or authorized agent:
Compensation laws of California. If,after making this certificate of exemption,1 Dale:
become subject to the Worker's Compensation provisions of the Labor Code,I must
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LF:NDINC.ACF.NC\'
1 hereby affirm(hon there is a construction lending agency for the performance of swrk's
APPLICANT CERTIFICATION for which this permit is issued(Sec-3097,Civ C.)
I cenify that I have read(his application and state 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 cons(ruction,and hereby authorize representatives of this city to enter Lender's Address
upon the above mentioned property for inspection purposes.(We)agree to save
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may aceme against said City in consequence of the ARCHITECT'S DECLARATION
granting of this permit.Additionally,the applicant understands and will comply I understand my plans shall be used as public records.
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18. Licensed Professional
Signature Dale