10050184I CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10228 PALO VISTA RD I CONTRACTO PERMIT NO: 10050184
OWNER'S NAME: CHARLES fi TERRI YAGER I P-,en v j ay p A I DATE ISSUED: 05/252010 1
OW'NER'S PHONE: 4082526626
❑'! LICENSED CON'TRACTOR'S DECLARATION
License Class R Lic. 4
Contractor �i u! /o. & Ir
_ Dated' 1�- �%O f O
hereby affirm Thal I am licensed under the provisions of Ch apt crr999
(commencing with Section 7000) of Division 3 oft he Business S Professions
Code and that mr 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 far by Section 3700 of the Labor Code, for the
performance of the work for which this pemrit is issued.
1 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
permit is issued.
APPLICANT CERTIFICATION
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
indemnify and keep harmless the City of Cupertino agairsst liabilities, judgments,
costs, and expenses which may accrue 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
9.18.
Signature ""Z// Date d!G- 2 /'zo'o
❑ OWNER - BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License Lmv for one of
the following two reasons:
1, as owner of the property, or my employees with wages as their sole compensation,
will do the work, and the structure is not intended oroDered for sale (Sec.7044,
Business S Professions Code)
Las owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec.7044, Business S Professions Code).
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
Compensation, as provided for by Section 3700 of the Labor Code, for the
perfonnanee of the work for which this permit is issued,
1 have and will mainain Worker's Compensation Insurance, as provided for by
Section 3700 of the Labor Code, for the performance of the work for which this
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 so as to become subject to the Worker's
Compensation laws of Cali fomia. If, after making this certificate of exemption, I
become subject to the Worker's Compensation previsions of the Labor Code, I must
Forthwith comply with such provisions or this permit shall be deemed revoked.
APPLICA\ T CERTIFICATION
I certify that I have mad 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
indemnify and keep hamdess the City of Cupertino against liabilities, judgments,
costs, and expenses which may accrue 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
9.18.
Signature
PHONE NO:
BUILDING PERMIT INFO: BLDG I— ELECT r PLUMB r
MECII ri RESIDENTIAL. r1 COM AI ERIC IA I, r
JOB DESCRIPTION: RITCIII:N(160SQ ),NON- STRUCTURAI., REMODELING AND
INSTALL 7 CAN LIGHT IN LIVING ROOM
Sy. Ft Floor Area: I Valualion: $37000
APN Number: 35702060.00 1 Occupancy Type:
PERMIT EXPIRES IF (YORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
Issued bv. Date: S ZL1O
RE- ROOFS:
All roofs shall be inspected prior to any roofing material being installed. Ira roof is
installed without first obtaining an inspection, 1 agree to remove all new materials for
inspection.
Signature of Applicant: Date:
ALL ROOF COVERINGS'TO BE CLASS "A" OR BE'17ER
HAZARDOUS MATERIALS DISCLOSURE
1 have read the hazardous materials requirements under Chapter 6.95 of the
California Health C Safety Code, Sections 25505, 25533, and 25534. 1 will maintain
compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health &
Safety Code, Section 25532(x) should 1 store or handle hazardous material.
Additionally, should 1 use equipment or devices which emit hazardous air
contaminants as defined by the Bar Area Air Quality Management District 1 will
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
Health S Safety Code. Sections 25505, 25533, and 25534.
Owner or authorized agent:
je o o� Date:
CONSTRUCTION LENDING AGENCY
I hereby affirm that them is a construction lending agency for the performance of work's
for which this permit is issued (See . 3097, Civ C.)
Lender's Name
Lender's
ARCIUTFC'I "S DECLARATION
I understand my plans shall be used as public records.
Licensed
CITY OF
CUPEkTINO
CITY OF CUPERTINO
ADDITION /REMODEL
PERMIT APPLICATION FORM
l 0S> CS'1 ZV
API\ # 1
1 5 09 060.
ate: S• ZS -(.O
Is a 2 "d unit being added? Yes ❑ No KJ If yes, please fill out the permit application for 2" unit.
Building Address: n
VIs
/o�dk /JAr-o .
Mailing Address (if different from building address):
Owner's N'a"me: ((,,
6f
Phone P
yoe
4GE2
01,E -6G�G
C�ontractor:
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Phone #: z V 9- S zl& /- d
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/C�>q�7' A0eIC19 � 6cD.E'S. PO
Fax #: yod'- vUG�-
Contractor License i#:
Cupertino Business License N:
Contact:
Phone t yos - Z/
0*4,CL t4 /4 � Z -
Fax M
Building Permit Info:
Bldg. Elect. Plumb. Mech. Eq— Hillside ❑
Job Description:
Addition -What is being added ?(Be Specific):
What is being remodeled (not including addition)?
61 n,/ /hl �k �� GGih ��'J•�'}'� Iti L�V�H� Y.��i
Remodel Includes Re -Roof: Yes ❑ No If yes list number of squares
Remodel Includes Structural: Yes ❑ No Ez
Do you have the pre- application planning approval? Yes ❑ No ❑
If yes, lease rovide a co y of your planning approval letter. Planners name:
Square Footage:
Addition: Porch: Deck: Garage: Detached Attached
Remodel: Kitchen /6 C/ Bath Other
Type of Construction (Usage Class):
Occupancy Type:
1 -A; I -B ❑ II /1111\/-A ❑ 11/111 B. IV -HT, V -B]
SLtG�� taFzyJLC y ��
Valuation: ,
'Please check this box if the project is a
�,
%j 3 ; c: o v
second -story addition ❑
Project Si c: Express ❑ Standard ❑ Large ❑ Major ❑
Please complete relevant portion of the Green Building
Checklist & attach it to the application or if applicable,
Green Building Points Achieved:
include in plan set & the sheet index.
** *For Office Use Only * **
Over- the - Counter ❑ Revised 07/06/09
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