10080056CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 800 HOOSHANG CT
OWNER'S NAME: M
pL LICENSED CONTRACTOR'S DECLARATION
License Class j) Lic. # tf 13 '1'-0fv'f.a.t.v ac,.~ f-o c.e;f;'/I7H) :t:,;IL .
Contractor ,.... I),t"tO'.) Date ''''2-7 II 0r ,
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 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
perfonnance of the work for which this pennit is issued.
I have and will maintain Worker's Compensation Insurance, as provided for by
Section 3700 of the Labor Code, for the perfonnance of the work for which this
permit 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 hannless the City of Cupertino against liabilities, judgments,
costs, and expenses which may accrue against said City in consequence of the
granting of this pennit. Additionally, the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code, Section
9.18.
Signature u Date 9/~'T (0
I
0 OWNER-BUILDER 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 ofthe property, am exclusively contracting with licensed contractors 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 for by Section 3700 of the Labor Code, for the
performance of the work for which this pennit is issued.
I have and will maintain Worker's Compensation Insurance, as provided for by
Section 3700 of the Labor Code, for the perfonnance ofthe 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
Compensation laws ofCalifomia. If, after making this certificate of exemption, I
become subject to the Worker's Compensation provisions ofthe Labor Code, I must
forthwith comply with such provisions or this pennit shall be deemed revoked.
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 hannless the City of Cupertino against liabilities, judgments,
costs, and expenses which may accrue against said City in consequence of the
granting of this pennit. Additionally, the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code, Section
9.18.
Signature Date
CONTRACTOR: MARVIN DAVIS
CONSTRUCTION
PERMIT NO: 10080056
1450 KOLL CIR DATE ISSUED: 0912712010
SAN JOSE, CA 95112 PHONE NO: (408)975-0200
BUILDING PERMIT INFO:
r
BLDG r ELECT r PLUMB r
MECH RESIDENTIAL r COMMERCIAL r
JOB DESCRIPTION: FIRE DAMAGE RE-BUILD 4 CAR CARPORT (FREE
STANDING)
880 SQIT
Sq. Ft Floor Area: Valuation: $25000
APN Number: 35902000.COMMON Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
IssuedbY~ Dat~'Z7_/tl
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 Applicant: 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 defined 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, Sections 25505, 25533, and 25534.
Owner or authorized agent:
::::> Date: ~7(/O/...J c-
CONSTRUCTION LE G AGENCY
I hereby aflinn that there is a construction lending agency for the perfonnance of work's
for which this pennit is issued (Sec. 3097, Civ C.)
Lender's Name
Lender's Address
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Licensed Professional