11060037CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10825 ALDERBROOK LN
CONTRACTOR: TELD
PERMIT NO: 11060037
OWNER'S NAME:
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PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION
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PERMIT INFO: BLDG �" " PLUMB
UILDI ELECT
License Class Lic. #
(7
Contractor Date
MECH RESIDENTIAL COMMERCIAL
I hereby affirm that I am licensed nder the provisiVsof hapter 9
JOB DESCRIPTION: ADD ONE BEDROOM,LIVING & READING ROOMS (727
(commencing with Section 7000) of Division 3 of the Business & Professions
SQFr)
SANITARY IS SUNNYVALE'S JURISDICTION.
Code and that my license is in full force and effect.
I hereby affirm under penalty of perjury one of the following two declarations:
► 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: $70000
permit is issued.
APPLICANT CERTIFICATION
APN Number: 36921050.00
Occupancy Type:
I certify that ► 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 against liabilities, judgments,
PERMIT EXPIRES IF WORK IS NOT STARTED
costs, and expenses which may accrue against said City in consequence of the
granting of thi ermit. Additionally, the applicant understands and will comply
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
with all non-p in source regulations per the Cupertino Municipal Co ; Secti
180 DAYS FROM LAST CALLED INSPECTION.
9.18.
Signature
I hereby affirm that I am exempt from the Contractor's License Law for one of
RE -ROOFS:
the following two reasons:
All roofs shall be inspected prior to any roofing material being installed. If a roof is
I, as owner of the property, or my employees with wages as their sole compensation,
installed without first obtaining an inspection, I agree to remove all new materials for
will do the work, and the structure is not intended or offered for sale (Sec.7044,
inspection.
Business & Professions Code)
I, as owner of the property, am exclusively contracting with licensed contractors to
Signature of Applicant: Date:
construct the project (Sec.7044, Business & Professions Code).
I hereby affirm under penalty of perjury one of the following three
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
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
performance of the work for which this permit is issued.
I have read the hazardous materials requirements under Chapter 6.95 of the
► have and will maintain Worker's Compensation Insurance, as provided for by
California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain
Section 3700 of the Labor Code, for the performance of the work for which this
compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health &
Safety Code, Section 25532(a) should I store or handle hazardous material.
permit is issued.
Additionally, should I use equipment or devices which emit hazardous air
I 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
not employ any person in any manner so as to become subject to the Worker's
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
Compensation laws of California. If, after making this certificate of exemption, ►
Ith &Safety Code, Sections 25505, 25533, and 25534.
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.
: 9
Date:
APPLICANT CERTIFICATION
CONSTRUCTION LENDING AGENCY
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
I hereby affirm that there is a construction lending agency for the performance of work's
to building construction, and hereby authorize representatives of this city to enter
for which this permit is issued (Sec. 3097, Civ C.)
upon the above mentioned property for inspection purposes. (We) agree to save
Lender's Name
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
costs, and expenses which may accrue against said City in consequence of the
Lender's Address
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
9.18.
I understand my plans shall be used as public records.
Signature Date
Licensed Professional
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SEP 07 2011 IU
September 2, 2011
City of Cupertino
Building Department
10300 Torre Avenue
Cupertino, CA 95014-3255
Subject: 10825 Alderbrook Lane, Cupertino, CA 95014
To Whom It May Concern:
Please be advised that the proposed building as referenced above will not have any
adverse impact on the City of Sunnyvale's sewer system.
Please call me if you have any questions at (408) 730-7636.
Very truly yours,
Kent Steffens
Director of Public Works
Bennett Chun, P.E.
Civil Engineer