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11080037CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10761 GASCOIGNE DR CONTRACTOR: ALI'S CONSTRUCTION & PERMIT NO: 11080037 REMODELING OWNER'S NAME: SAN JOSE, CA 95112 PHONE NO: (408) 898-6474 LDS LICENSED CONTRACTOR'S DECCLARATION r r r License Class Lic. # Z3 8 3 BUILDING PERMIT INFO: BLDG ELECT PLUMB r r r MECH RESIDENTIAL COMMERCIAL ContractorYr AAAA2LDateg 23_l� I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION: DEMOLITON SFDWL(1380SQFT) (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: 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 performance of the work for which this permit is issued. Sq. Ft Floor Area: Valuation: $0 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 APN Number: 37531023.00 Occupancy Type: permit is issued. APPLICANT CERTIFICATION 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 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 k p harmless the City of Cupertino against liabilities, judgments, 180 DAYS FROM LAST CALLED INSPECTION. against said City in consequence of the costs, and expFF granting of the applicant understands and will comply with all non- Fr the Cupertino Code, Section 9.18. � Issued Date: Signature Date 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) I, 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 1 have and will maintain a Certificate of Consent to self -insure for Worker's California Health & Safety Code, Sections 25505, 25533, and 25534. 1 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 permit is issued. maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Sections 25505,25533, a 5 4. 1 certify that in the performance of the work for which this permit is issued,l shall not employ any person in any manner so as to become subject to the Worker's Owner or h d gent: 1� Compensation laws of California. If, after making this certificate of exemption, 1 Date: 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 LENDING AGENCY 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, costs, and expenses which may accrue 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 Date CITY OF CUPERTINO Fm--7 FEE ESTIMATOR - BUILDING DIVISION VADDRESS: d1APN: 10761 gascoigne dr. DATE: 08/04/2011 REVIEWED BY: bobs. —7BP#: 'VALUATION: 1$5,800 *PERMIT TYPE: Demolition Permit PRIMARY SFD or Duplex PENTAMATION 1SFDWL-DEM PERMIT TYPE: WORK demo 1 story sfd. SCOPE FEE ID FLR AREA (S.f.) 1DEMORES 1,380 NOTF.- Thp.vp f-p-v are hated an the nroliminary infarmalinn availahlo and arp i)nlv an pvfimah, (-nntart the DPW far addn I/ info_ FEEITEMS (Fee Resolution 11-053 Eff 711111) FEE QTY/FEE MISC ITEMS Tslfpp . 1,C Fee Phim 4) : " Vech, J- Permit Fee: $523.00 Suppl. Insp. Fee4S Reg. 0 OT 0.0 hrs $0.00 f Strong Motion Fee: IBSEISMCR $0.58 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $1.00 SUBTOTALS: j $524.58 j $0.00 TOTAL FEE: $524.58 Revised: 07/04/2011