10080128 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10953 SWEET OAK ST COT TRACTOR:BAY AREA CUSTOM PERMIT NO: 10080128
BUILDERS INC
OWNER'S NAME: GIGI LUGONIA 1002 S DE ANZA BLVD!STE Al DATE ISSUED:08/18/2010
NER'S PHONE: 6502699907 SAN JOSE,CA 95129 PHONE NO:(408)446-1200
13 LICENSED CONTRACTOR'S DECLARATION '
BUDDING PERMIT;INFO: BLDG r ELECT r PLUMB r
License Class_ �;� Lic.#_ �;fr 2_ r� G
/tit ( )t!� 6,"acr� MECH r RESIDENTIAL� COMMERCIAL r
Contractor f� tri Date
I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:!REMODEL KITCHEN(140SQ);NO RE-ROOF&NO
(commencing with Section 7000)of Division 3 of the Business&Professions STRL CTURAL
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.
1 have and will maintain Worker's Compensation Insurance,as provided for by Sq.F Floor Area: Valuation:$10000
Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued.
t�
APPLICANT CERTIFICATION APN Vumber:32651014.00 Occupancy Type:
I certify that 1 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 construction,and hereby authorize representatives of this city to enter ]PERMIT EXPIRES IF WORK IS NOT STARTED
upon the above mentioned property for inspection purposes. (We)agree too save i
indemnify and keep harmless the City of Cupertino against liabilities,judgments, WITHIN 180 DAYS OF PERMIT ISSUANCE OR
costs,and expenses which may accrue against said City in c consequence the 180 DAYS FROM LAST CALLED INSPECTION.
granting of this permit. Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18.
,, Issue I by Dat l"
Signature 6:Lr�' Date
v
L OWNER-BUILDER DECLARATION RE-ROOFS:
1 hereby affirm that I am exempt from the Contractor's License Law for one of `411 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,I agree to remove all new materials for
1,as owner of thero inspec.ion.
p perry,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, Signat ire of Applicant: Date:
Business&Professions Code)
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
I hereby affirm under penalty of perjury one of the following three
declarations: HAZARDOUS MATERIALS DISCLOSURE
1 have and will maintain a Certificate of Consent to self-insure for Worker's I have read the hazardous'materials requirements under Chapter 6.95 of the
Compensation,as provided for by Section 3700 of the Labor Code,for the Califoi•nia Health&Safety Code,Sections 25505,25533,and 25534. 1 will maintain
performance of the work for which this permit is issued. compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
I have and will maintain Worker's Compensation Insurance,as provided for by Safety Code,Section 25532(a)should I store or handle hazardous material.
Section 3700 of the Labor Code,for the performance of the work for which this Additi finally,should I use equipment or devices which emit hazardous air
permit is issued. contaminants as defined by the Bay Area Air Quality Management District 1 will
1 certify that in the maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
fy performance of the work for which this permit is issued,I shall Health&Safety Code,Sections 25505,25533,and 25534.
not employ any person in any manner so as to become subject to the Worker's
Compensation laws of California. If,after making this certificate of exemption,I Owner or authorized ag t:
become subject to the Worker's Compensation provisions of the Labor Code,1 must Date:_�a��[, /I('
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
APPLICANT CERTIFICATION I hereb.-affirm that there is a construction lending agency for the performance of work's
1 certify that I have read this application and state that the above information is for whi:h this permit is issued(Sec.3097,Civ C.)
correct.I agree to comply with all city and county ordinances and state laws relating Lender's Name
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes.(We)agree to save Lender's Address
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
cr nd expenses which may accrue against said City in consequence of the
g" g of this permit.Additionally,the applicant understands and will comply ARCHITECT'S DECLARATION
with all non-point source regulations per the Cupertino Municipal Code,Section 1 under,tand my plans shall lie used as public records.
9.18.
Signature
Date !2� Licenscd Professional