09070017 CITY OF CUPERTINO BUILDING PERMIT
BUILDINGADDRESS: 10327 VISTA KNOLL BLVD CONTRACTOR:TIMELINE PERMIT NO:09070017
CONSTRUCTION
OWNER'S NAME: SANDRA MA&NEIL SO 14401 BIG BASIN WAY DATE ISSUED:09/14/2009
OWNER'S PHONE: 6506198091 SARATOGA,CA 95070 PHONE NO:(409)741-3000
LICENSED CONTRACTOR'S DECLARATION r r r
,5.9 BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class ./ %L v Lic.#
,may MECH r RESIDENTIAL r COMMERCIAL r
ContractorDate
I hereby affirm that 1 am licensed under the provisions of Chapter 9 JOB DESCRIP'rION:REVISION-SLIGHT CHANGE IN GIRDER
(commencing with Section 7000)of Division 3 of the Business&Professions SUPPORT AT ONE
Code and that my license is in full force and effect. SECTION OF FOUNDATION;ORIG#09020011-NO NEW
PERMIT.
1 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 Sq.Ft Floor Area: Valuation:S0
permit is issued.
APPLICANT CERTIFICATION APNNumber.32613121.01 Occupancy Type:
1 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 PERMIT EMPIRES IF WORK [S NOT STARTED
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the WITHIN 180 DAYS OF PERMIT ISSUANCE OR
granting of this permit. 9 itionxlly,the applicant understands and will comply 180 DAYS FROM LAST CALLED INSPECTION.
with all non-point soure6 egulatiom per t upenino Municipal Code,Section
9.18. _
Issued by: Date:�l�j pS
$IgmaNre Dale
❑ OWNER-BUILDER DECLARATION
RF.-ROOFS:
I hereby affirm that 1 am exempt from the Contractor's License Law for one of All roofs shall be inspected prior to any roofing material being installed.If a roof is
the following two reasons: installed without first obtaining an inspection,1 agree to remove all new materials for
I,as owner of the property,or my employees with wages as their sole compensation,
inspection.
will do the work and the structure is not intended or offered for sale($x.7044,
Business&Professions Code) Signature of Applicant: Date:
I,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sm.7044,Business&Professions Code).
ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
hereby affirm under penalty of perjury one of the following three
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. California Health&Safety Code,Sections 25505,25533,and 25534. 1 will maintain
I have and will maintain Worker's Compensation Insurance,as provided forby compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
Section 3700 of the labor Code,for the performance of the work for which this Safely Code,Section 25532(x)should I store or handle hazardous material.
permit is issued. Additionally,should I use equipment or devices which emit hazardous air
1 certify that in the performance of the work for which this permit is issued,I shall contaminants as defined by the Bay Area.Air Quality Management District I will
maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
not employ any person in any manner so as to become subject to the Worker's 11
Health&Sa(ej Code,SC o s 25505,25573,and 25574.
Compensation laws of California. If,after making this certificate of exemption,I / //
become subject to the Worker's Compensation provisions of the Labor Code,I must Owge�or apthoriz a y��r y
forthwith comply with such provisions or this permit shall be deemed revoked. Date:
APPLICANT CERTIFICATION CONSTRUCTION LENDING AGENCY
1 certify that 1 have read this application and state that the above information is I hereby affirm that there is a contraction lending agency for the performance of work's
correct.I agree to comply with all city and county ordinances and state laws relating for which this permit is issued(Sm.3097,Civ C.)
to building construction,and hereby authorize representatives of this city to enter Lender's Name
upon the above mentioned property for inspection purposes.(We)agree to save
indemnify and keep harmless the City of Cupertino against liabilities,judgments, Lender's Address
costs,and expenses which may acerae against said City in consequence of the
granting of this permit.Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section ARCHITECT'S DECLARATION
9.1& 1 understand my plans shall be used as public records.
Signaturc fate Licensed Professional
!,Lei CITY OF CUPERTINO0�( O� v0 ► -1
CITY Of
CUPERTINO REVISION/DEFERRED
PERMIT APPLICATION FORM
APN # / Date: 7_ G -�POa�'
Original Permit#:
Building Address: 3vZ7 /u�, [o�Jeri»b r C 4 9S'o/q'
Mailing Address (if different from building address):
Owner's Name: A/jq—$d Phone #:
.!tl�FA/ . iso-6(q- �oql
Contractor: /I II Phone: 4i0 ft aDG -y3is
Fax: `/o S 7,/ 7
Contractor License #:
Cupertino Business License #: o?;�a3 rO
Contact'511, Phone: ypI p�6
Fax:
Building Permit Info:
Bldg )OElect ❑ Plumb ❑ Mech ❑
Residential Commercial ❑
Job Description: !�
Is the project in the Witdland- Urban Interface Fire Area? Yes ❑ No ❑
Type of Construction (Usage Class): * Occupancy Type:
1-A, 1-B ❑ II/IIIN-A ❑ II/I11 B, IV-HT, V-B ❑
Valuation (cost of project): opo
Project Size: Express Standard Large Major
Green Building: Please complete relevant portion of the Green Building/LEED Checklist & attach it
to the application or if applicable, include in plan set & the sheet index.
Points Achieved:
For help, contact Build it Green at www.builditgreen.org
Revised 01/07/09