11100154 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 7373 FALLENLEAF LN CONTRACTOR:DUPLAN CONSTRUCTION PERMIT NO: 11100154
INC.
OWNER'S NAME: LYLES DIVERSIFIED INC 390 INDUSTRIAL ST DATE ISSUED: 10/21/2011
'7NER'S PHONE: 4082070247 CAMPBELL,CA 95008 PHONE NO:(408)866-6682
0 LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class Z—r- Lic.# /7
n �j6 MECH]_ RESIDENTIAL F_ COMMERCIAL�
Contractor�P14y1 S Date C/�Z��G�
I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:REPLACE WATER BACKFLOW PREVENTOR
(commencing with Section 7000)of Division 3 of the Business&Professions
Code and that my 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 for by Section 3700 of the Labor Code,for the
performance of the work for which this permit is issued. Sq.Ft Floor Area: Valuation:$2000
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
APN Number:35927025.00 Occupancy Type:
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 PERMIT EXPIRES IF WORK IS NOT STARTED
to building construction,and hereby authorize representatives of this city to enter
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, 180 DAYS FROM LAST CALLED INSPECTION.
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 Issued by �- Date: hf
9.18.
Signature Date v /
RE-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 I am exempt from the Contractor's License Law for one of inspection.
the following two reasons:
1,as owner of the property,or my employees with wages as their sole compensation, Signature of Applicant: Date:
will do the work,and the structure is not intended or offered for sale(Sec.7044,
Business&Professions Code)
1,as owner of the property,am exclusively contracting with licensed contractors to 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: I have read the hazardous materials requirements under Chapter 6.95 of the
I have and will maintain a Certificate of Consent to self-insure for Worker's California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain
Compensation,as provided for by Section 3700 of the Labor Code,for the compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
performance of the work for which this permit is issued. Safety Code,Section 25532(a)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 Bay Area Air Quality Management District I will
maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
permit is issued. Health&Safety Code,Sections 25505,25533,and 25534.
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 Owne rued a
Compensation laws of California. If,after making this certificate of exemption,I Date: /
become subject to the Worker's Compensation provisions of the Labor Code,I must
q4�
forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of work's
APPLICANT CERTIFICATION for which this permit is issued(Sec.3097,Civ C.)
I certify that I have read this 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 construction,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, ARCHITECT'S DECLARATION
and expenses which may accrue against said City in consequence of the
ng 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 Date
GENERAL PERMIT APPLICATION MEP
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255
CUPERTINO (408)777-3228• FAX(408)777-3333• building(cDcupertino.org MISC
PLUMBING MECHANICAL ❑ELECTRICAL ❑MISCELLANEOUSy�
PROJECT ADDRESf7,37) AFN#
OWNER NAM E MAII_ G
STREET ADDRESS � � CITY, STATE,�. l FAX
i
CONTACT NAME 12 PHONE E-MAIL.
STREETADDRESS CITY,STATE, ZIP FAX
❑OWNER ❑ OWNER-B=ER ❑ OWNER AGENT XCONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHrrECT ❑ENGINEER ❑ DEVELOPER ❑TENANT
CONTRACTOR NAME LICENSE NUMBER LICENSE TYPE BUS.LIC#
COMPANY NAME ` /,,_ F
E- / ? 25 L
STREET ADDRESS +d CITY,STATE,ZIP PHONE e
�(t, >
ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC#
COMPANY NAME' E-MAIL. FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF ❑SFD or DUPLEXMULTI-FAMILY PROJECT IN WILDLAND ❑ YES PROJECT IN ❑YES IS THE BLDG AN ❑YES
BUILDING. ❑COMMERCIAL URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑NO EICHLER HOME? ❑NO
DESCRIPTION OF WORK
TOTAL VALUATION: RECEIVED BY:
By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on the property owner's behalf. I have read this
application and the information I have providedis cone , have read the Description of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating to building c s I authorize r entatives of Cupertino to enter the above-id ti, property for inspection pu{poses.
Signature of Applicant/Agentt Date:
SUPPLEttNIA14INtRMATION REQUIRED OFFICE USE ONLY
LJ OVER-THE-COUNTER
a
❑ EXPRESS
Y
U
❑ STANDARD
U
aZ ❑ LARGE
a
❑ MAJOR
MEPMiscApp_2011.doc revised 06/21/11
Building Department
City Of Cupertino
10300 Torre Avenue
Cupertino, CA 95014-3255
Telephone: 408-777-3228
C U P E RTI N O Fax: 408-777-3333
CONTRACTOR/ SUBCONTRACTOR LIST
JOB ADDRESS: 3 PERMIT#
OWNER'S NAME: (¢_.1 -c- PHONE# — e--
GENERAL CONTRACTOR- BUSINESS LICENSE# /
ADDRESS: v - CITY/ZIPCODE: C G
*Our municipal code requires all businesses working in the city to have a City of Cupertino business license.
NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE
GENERAL CONTRACTOR AND ALL SUBCONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO
BUSINESS LICENSE. //
I am not using any subcontractors:
Signature ate
Please check applicable subcontractors and complete the following information:
V SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets & Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring / Carpeting
Linoleum /Wood
Glass / Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Painting/Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/Contractor Signature Date
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 7373 FALLENLEAF LN CONTRACTOR:DUPLAN CONSTRUCTION PERMIT NO: 11100154
INC.
OWNER'S NAME: LYLES DIVERSIFIED INC 390 INDUSTRIAL ST DATE ISSUED: 10/21/2011
'7NER'S PHONE: 4082070247 CAMPBELL,CA 95008 PHONE NO:(408)866-6682
0 LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class Z—r- Lic.# /7
n �j6 MECH]_ RESIDENTIAL F_ COMMERCIAL�
Contractor�P14y1 S Date C/�Z��G�
I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:REPLACE WATER BACKFLOW PREVENTOR
(commencing with Section 7000)of Division 3 of the Business&Professions
Code and that my 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 for by Section 3700 of the Labor Code,for the
performance of the work for which this permit is issued. Sq.Ft Floor Area: Valuation:$2000
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
APN Number:35927025.00 Occupancy Type:
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 PERMIT EXPIRES IF WORK IS NOT STARTED
to building construction,and hereby authorize representatives of this city to enter
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, 180 DAYS FROM LAST CALLED INSPECTION.
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 Issued by �- Date: hf
9.18.
Signature Date v /
RE-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 I am exempt from the Contractor's License Law for one of inspection.
the following two reasons:
1,as owner of the property,or my employees with wages as their sole compensation, Signature of Applicant: Date:
will do the work,and the structure is not intended or offered for sale(Sec.7044,
Business&Professions Code)
1,as owner of the property,am exclusively contracting with licensed contractors to 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: I have read the hazardous materials requirements under Chapter 6.95 of the
I have and will maintain a Certificate of Consent to self-insure for Worker's California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain
Compensation,as provided for by Section 3700 of the Labor Code,for the compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
performance of the work for which this permit is issued. Safety Code,Section 25532(a)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 Bay Area Air Quality Management District I will
maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
permit is issued. Health&Safety Code,Sections 25505,25533,and 25534.
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 Owne rued a
Compensation laws of California. If,after making this certificate of exemption,I Date: /
become subject to the Worker's Compensation provisions of the Labor Code,I must
q4�
forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of work's
APPLICANT CERTIFICATION for which this permit is issued(Sec.3097,Civ C.)
I certify that I have read this 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 construction,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, ARCHITECT'S DECLARATION
and expenses which may accrue against said City in consequence of the
ng 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 Date
GENERAL PERMIT APPLICATION MEP
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255
CUPERTINO (408)777-3228• FAX(408)777-3333• building(cDcupertino.org MISC
PLUMBING MECHANICAL ❑ELECTRICAL ❑MISCELLANEOUSy�
PROJECT ADDRESf7,37) AFN#
OWNER NAM E MAII_ G
STREET ADDRESS � � CITY, STATE,�. l FAX
i
CONTACT NAME 12 PHONE E-MAIL.
STREETADDRESS CITY,STATE, ZIP FAX
❑OWNER ❑ OWNER-B=ER ❑ OWNER AGENT XCONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHrrECT ❑ENGINEER ❑ DEVELOPER ❑TENANT
CONTRACTOR NAME LICENSE NUMBER LICENSE TYPE BUS.LIC#
COMPANY NAME ` /,,_ F
E- / ? 25 L
STREET ADDRESS +d CITY,STATE,ZIP PHONE e
�(t, >
ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC#
COMPANY NAME' E-MAIL. FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF ❑SFD or DUPLEXMULTI-FAMILY PROJECT IN WILDLAND ❑ YES PROJECT IN ❑YES IS THE BLDG AN ❑YES
BUILDING. ❑COMMERCIAL URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑NO EICHLER HOME? ❑NO
DESCRIPTION OF WORK
TOTAL VALUATION: RECEIVED BY:
By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on the property owner's behalf. I have read this
application and the information I have providedis cone , have read the Description of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating to building c s I authorize r entatives of Cupertino to enter the above-id ti, property for inspection pu{poses.
Signature of Applicant/Agentt Date:
SUPPLEttNIA14INtRMATION REQUIRED OFFICE USE ONLY
LJ OVER-THE-COUNTER
a
❑ EXPRESS
Y
U
❑ STANDARD
U
aZ ❑ LARGE
a
❑ MAJOR
MEPMiscApp_2011.doc revised 06/21/11
Building Department
City Of Cupertino
10300 Torre Avenue
Cupertino, CA 95014-3255
Telephone: 408-777-3228
C U P E RTI N O Fax: 408-777-3333
CONTRACTOR/ SUBCONTRACTOR LIST
JOB ADDRESS: 3 PERMIT#
OWNER'S NAME: (¢_.1 -c- PHONE# — e--
GENERAL CONTRACTOR- BUSINESS LICENSE# /
ADDRESS: v - CITY/ZIPCODE: C G
*Our municipal code requires all businesses working in the city to have a City of Cupertino business license.
NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE
GENERAL CONTRACTOR AND ALL SUBCONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO
BUSINESS LICENSE. //
I am not using any subcontractors:
Signature ate
Please check applicable subcontractors and complete the following information:
V SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets & Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring / Carpeting
Linoleum /Wood
Glass / Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Painting/Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/Contractor Signature Date
CITY OF CUPERTINO BUILDING PE
BUILDING ADDRESS: 7373 FALLENLEAF LN CONTRACTOR:TEAMWRKX : 10100051
OWNER'S NAME: KIRK KOSLOWSKI 1691 OLD BAYSHORE HWY DATE ISSUED:03/17/2011
—/ER'S PHONE: 4082070230 SAN JOSE,CA 95112 PHONE NO:(408)287-2700
W LICENSED CONTRACTOR'S DECLARATION
'r,r BUILDING PERMIT INFO: BLDG ELECT PLUMB i
License Class Lie.# ��-��d r' �- (--
MECH RESIDENTIAL COMMERCIAL
Contractor_r6w,W,'1L Co,As+ Date (0 - 4- I I
hereby affirm that 1 am licensed under the provisions of Chapter 9 JOB DESCRIPTION:TO CLEAR CODE VIOLATION: PHASE[-REPAIR
(commencing with Section 7000)of Division 3 of the Business&Professions EXTERIOR EXIT BALCONY.DEMOLISH STORAGE ROOM AND
Code and that my license is in full force and effect. EXIT STAIRWAY.ADD TWO NEW EXIST
10/4/2011-REV#I -REVISE ELECTRICAL SERVICE,ADD NEW I-IGHTS,REVISE:
hereby affirm under penalty of perjury one of the following two declarations: STAIRS,ADD CAIN RAIL GUARD-REV#1 ISS'D 10/4/2011
1 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
perfonnance 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
permit is issued. Sq.Ft Floor Area: Valuation:$50000
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is APN Number:35927025.00 Occupancy Type:
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 this permit. Additionally,the applicant understands and will comply WITHIN 180 DAYS OF PERMIT ISSUANCE OR
with all non-point source regulations per the Cupertino Municipal Code,Section 180 DAYS FROM LAST CALLED INSPECTION.
9.18.
Signatur %0, C.�/fi . Date /O Issued b
v y: Date:
OWNER-BUILDER DECLARATION
1 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 rooting material being installed.11'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)
1,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
I have and will maintain Worker's Compensation Insurance,as provided for by California Health&Safety Code,Sections 25505,25533,and 25534. 1 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 1 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 1 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 Califoria. If,after making this certificate of exemption,I health&Safety Code,Sections 25505,25533,and 25534.
become subject to the Worker's Compensation provisions of the Labor Code,I must
O n or authorized agent:
forthwith comply with such provisions or this permit shall be deemed revoked. Date:/O.- -,4 If
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%pork'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,
C and expenses which may accrue against said City in consequence of time Lender's Address
ig of this permit.Additionally,the applicant understands and will comply
.:u all non-point source rcgulatiens per the Cupertino Municipal Code,Section ARCHITECT'S DECLARATION
9.18.
1 understand my plans shall be used as public records.
Signature Date
Licensed Professional
CITY OF CUPERTINO BUILDING PE
BUILDING ADDRESS: 7373 FALLENLEAF LN CONTRACTOR:TEAMWRKX : 10100051
OWNER'S NAME: KIRK KOSLOWSKI 1691 OLD BAYSHORE HWY DATE ISSUED:03/17/2011
—/ER'S PHONE: 4082070230 SAN JOSE,CA 95112 PHONE NO:(408)287-2700
W LICENSED CONTRACTOR'S DECLARATION
'r,r BUILDING PERMIT INFO: BLDG ELECT PLUMB i
License Class Lie.# ��-��d r' �- (--
MECH RESIDENTIAL COMMERCIAL
Contractor_r6w,W,'1L Co,As+ Date (0 - 4- I I
hereby affirm that 1 am licensed under the provisions of Chapter 9 JOB DESCRIPTION:TO CLEAR CODE VIOLATION: PHASE[-REPAIR
(commencing with Section 7000)of Division 3 of the Business&Professions EXTERIOR EXIT BALCONY.DEMOLISH STORAGE ROOM AND
Code and that my license is in full force and effect. EXIT STAIRWAY.ADD TWO NEW EXIST
10/4/2011-REV#I -REVISE ELECTRICAL SERVICE,ADD NEW I-IGHTS,REVISE:
hereby affirm under penalty of perjury one of the following two declarations: STAIRS,ADD CAIN RAIL GUARD-REV#1 ISS'D 10/4/2011
1 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
perfonnance 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
permit is issued. Sq.Ft Floor Area: Valuation:$50000
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is APN Number:35927025.00 Occupancy Type:
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 this permit. Additionally,the applicant understands and will comply WITHIN 180 DAYS OF PERMIT ISSUANCE OR
with all non-point source regulations per the Cupertino Municipal Code,Section 180 DAYS FROM LAST CALLED INSPECTION.
9.18.
Signatur %0, C.�/fi . Date /O Issued b
v y: Date:
OWNER-BUILDER DECLARATION
1 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 rooting material being installed.11'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)
1,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
I have and will maintain Worker's Compensation Insurance,as provided for by California Health&Safety Code,Sections 25505,25533,and 25534. 1 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 1 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 1 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 Califoria. If,after making this certificate of exemption,I health&Safety Code,Sections 25505,25533,and 25534.
become subject to the Worker's Compensation provisions of the Labor Code,I must
O n or authorized agent:
forthwith comply with such provisions or this permit shall be deemed revoked. Date:/O.- -,4 If
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%pork'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,
C and expenses which may accrue against said City in consequence of time Lender's Address
ig of this permit.Additionally,the applicant understands and will comply
.:u all non-point source rcgulatiens per the Cupertino Municipal Code,Section ARCHITECT'S DECLARATION
9.18.
1 understand my plans shall be used as public records.
Signature Date
Licensed Professional