090600010
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 21408 KRZICH PL
OWNER'S NAME: I
LICENSED CONTRACTOR'S DECLARATION
License Class Lic. #
Contrnctor Date
I hereby affirm that I am licensed under the provisions of Chapter 9
(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 declaratil)ns:
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
perfonnance of the work for which this pennit is issued.
I have and will maintain Worker's Compensation Insurnnce, as provided for by
Section 3700 of the Labor Code, for the performance of the work for which this
pennit is issued.
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above infonnation 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,
costs, and expenses which may ac~rue against said City in consequence of the
grnnting ofthis pennit. Additionally, the applicant understands and will comply
;',';,".,.-po;.'wo~, re",,,,,i'M 7:1l"""i" MO$""
" ~. (\) y ::fa Signature ;;&c Date t Y
[i OWNER-Bl1ILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons:
I, as owner of the property, or my employees with wages as their sole compensation,
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 contrncting with licensed contrnctors to
construct the project (Sec.7044, Business & Professions Code).
I 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
Compensation, as provided fer by Section 3700 of the Labor Code, for the
perfonnance of the work for which :his pennit is issued.
I have and will maimain W"rker's Compensation Insurnnce, as provided for by
Section 3700 of the Labor Code, for the perfonnance of the work for which this
pennit is issued.
I certify that in the perfonnance of the work for which this pennit is issued, I shall
not employ any person in any manner so as to become subject to the Worker's
Compensatic!D laws of California. If, after making this certificate of exemption, I
become ~ubject to the Worker's Compensation provisions of the Labor Code, I must
forthwith comply with such provisions or this pennit shall be deemed revoked.
APPLICANT CERTIFICATION
I certify that I haVf~ read this application and state thal the above infonnation is
correct. I agree to comply with all ~ity and county ordinances and state laws relatmg
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 hannless the City of Cupertino against liabilities, judgments,
ccsts, and expenses which may accrue against said City in consequence of the
grnnting of this pennit. Additionally, the applicant understands and will comply
with all non-point source reg'.Ilations per the Cupertino Municipal Code, Section
9.18. l}Lr~{ Ol, Il!b-tt f 1 e
CONTRACTOR: TBD -TO BE PFRt'\1IT NO: 09060001
DETERMINED
DATE ISSUED: 0811 7/2009
PHONE NO:,
r r" I
BUILDING PERMIT INFO: BLDG ELECT PLUMB
r r r-,
MECD RESIDENTIAL COMMERCIAL
JOB DESCRIPTION: RMDL KITCHN/FAM RM (200SQ);NO RE-RF
& YES
STRUCTURAL
Sq. Ft Floor Area: Valuation: $30000
APN Number: 36206040.00 Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
Issued by: Date:
RE-ROOFS:
All roofs shall be inspected prior to any roofing material being installed. If a roof is
installed without first obtaining an inspection, I agree to remove all new materials for
inspection.
Signature of Appli~ant: Date:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
HAZARDOUS MATERIALS DISCLOSURE
I have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505.25533, and 25534. I will
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
Health & Safety Code, Section 25532(a) should I store or handle hazardous
material. Additionally, should I use equipment or devices which emit hazardous
air contaminants as ~efined by the Bay Area Air Quality Management District I
will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and
the Health & Safety Code, Sec:ions 25505, Z.5533, ~.
Owner or lIuthorized agent: D3t$"/1-1/01Z/;u. (j? .' ,
CON ENDING AGENCY
I hereby affinn that there is a construction lending agency for the perfonnance of
work's for which tt,is pennit is issued (Sec. 3097, Civ C)
Lender's Name
Lender's Address
ARCHITECT'S DECLARAnON
-~
I understand my plans shall be used JS public records.
Licensed Professional