11060164CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 1013 WESTLYNN WAY
CONTRACTOR: ANTHONY HODDER
PERMIT NO: 11060164
CONSTRUCTION
OWNER'S NAME:
CUPERTINO, CA 95014
PHONE NO: (408) 257-4317
❑ ENSED CONTRACTOR'S DECLARATION
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BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class Lie.k
MECH RESIDENTIAL COMMERCIAL
Contracto`C
I hereby affirm that I am licensed nde rovisions of Chapter 9 /
JOB DESCRIPTION: KITCHEN REMODEL(14SQFT), ENCLOSE
(commencing with Section 7000) of Division 3 of the Business & Professions
LA ADDWINDOW
&ADD BAY WINDOW
Code and that my license is in full force and effect.
I hereby affirm under penalty of perjury one of the following two declarations:
l 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: $50000
permit is issued.
APPLICANT CERTIFICATION
APN Number: 35926042.00
Occupancy Type:
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 coinstruc'ion6 ereby authorize representatives of this city to enter
upon the above men ned pr perry for inspection purposes. (We) agree to save
indemnify and k harmles the City of Cupertino agaAliab�ilifiements,PERMIT
'nst
EXPIRES IF WORK IS NOT STARTED
costs, and expe es which ay accrue ag
said
180 DAYS FROM LAST CALLED INSPECTION.
by: -- Date.
❑ OWNER -BUILDER DECLARATION
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).
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. 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.
Additio y 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
conta inan 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
mai ain co pliance with a Cuperti o unicipal Code, Chapter 9.12 and the
Compensation laws of California. If, after making this certificate of exemption, I
He th & S ety Code, s 2550 25 3, an 5 4.
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.
t/
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 Mork'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