11030125CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 21867 SHATTUCK DR
CONTRACTOR:
PERMIT NO: 11030125
OWNER'S NAME 9Rr•BEENA DAS 41 S%Q/lld/-
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DATE ISSUED: 03/28/2011
(' "NER'S PHONE: 4088385227 lei
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PHONE NO:
LSI LICENSED CONTRACTOR'S DELLARATION
BUILDING PERMIT INFO:
/License Class I,ic. #'.
BLDG ELECT PLUMB
MECH RESIDENTIAL COMMERCIAL
Contractor pate F7`� N2-� �z
hereby affir am licensed under the provisions of Chapter 9
JOB DESCRIPTION: REMOVE NON-BEARING WALL, INSTALL NEW 9" PSL
(comme ng with Section 7000) of Division 3 of the Business & Professions
BEAM
Code and that my license is in full force and effect.
"SEE NOTES**
1 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.
I have and will maintain Worker's Compensation Insurance, as provided for by
Sq. Ft Floor Area:
Valuation: $1000
Section 3700 of the Labor Code, for the performance of the work for which this
permit is issued.
APPLICANT CERTIFICATION
APN Number: 35614003.00
Occupancy Type:
I certify that I have read this application and state that the above information is
correct. 1 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
PERMIT EXPIRES IF WORK IS NOT STARTED
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
costs, and expenses which may accrue against said City in consequence of the
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
granting of this permit. Additionally, the applicant understands and will comply
180 DAY OM LAST CALLED INSPECTION.
with all non -point source regulations per the Cupertino Municipal Code, Section
9.18.
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Signature _ _ - Date CD '% z.E✓�
Issued by: { Date:
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OWNER -BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractor's License Law for one of
RE -ROOFS:
All roofs shall be inspected prior to any roofing material being installed. If a roof is
the following two reasons:
installed without first obtaining an inspection, 1 agree to remove all new materials for
1, as owner of the property, or my employees with wages as their sole compensation,
inspection.
will do the work, and the structure is not intended or offered for sale (Sec.7044,
Business & Professions Code)
Signature of Applicant: Date:
1, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec.7044, Business & Professions Code).
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
1 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
HAZARDOUS MATERIALS DISCLOSURE
Compensation, as provided for by Section 3700 of the Labor Code, for the
1 have read the hazardous materials requirements under Chapter 6.95 of the
performance of the work for which this permit is issued.
California Health & Safety Code, Sections 2550.5, 25533, and 25534. I will maintain
I have and will maintain Worker's Compensation Insurance, as provided for by
compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health &
Section 3700 of the Labor Code, for the performance of the work for which this
Safety Code, Section 25532(a) should 1 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, l shall
contaminants as defined b the Ba Area Air
y y Quality Management District 1 will
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
not employ any person in any manner so as to become subject to the Worker's
Health & Safety Code, Sections 25505, 25533, and 2.5534.
Compensation laws of California. If, after making this certificate of exemption, I
become subject to the Worker's Compensation provisions of the Labor Code, I must
Forthwith comply with such this be deemed
Owner o t•
Date: E�� Z" 12"t -'Z,) L�
provisions or permit shall revoked.
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APPLICANT CERTIFICATION
CONSTRUCTION LENDING AGENCY
certify that I have read this application and state that the above information is
1 hereby affirm that there is a construction lending agency for the performance of %ork's
,orrect. I agree to comply with all city and county ordinances and state laws relating
for which this permit is issued (Sec. 3097, Civ C.)
o building construction, and hereby authorize representatives of this city to enter
Lender's Name
ipon the above mentioned property for inspection purposes. (We) agree to save
ndemnify and keep harmless the City of Cupertino against liabilities, judgments,
Lender's Address
;osis, and expenses which may accrue against said City in consequence of the
;r g of this permit. Additionally, the applicant understands and will comply
A non -point source regulations per the Cupertino Municipal Code, Section
ARCHITECT'S DECLARATION
1 understand my plans shall be used as public records.
signature_ Date
Licensed Professional