10050100CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 18996 PENDERGAST AVE CONTRACTOR: HENRY LITTLE TRACTOR PERMIT NO: 10050100
SERVICE
1.dWER'S NAME:
1 SAN JOSE, CA 95124 1 PHONE NO: (408)377-0504 1
❑ LICENSED CONTRACTOR'S DECLARATION
License Class Lic. #
Contractor
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 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
Section 3300 of the. Labor -Code, for the performance -of the_work for—which1his-
permit is issued.
APPLICANT CERTIFICATION
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 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 accrue against said City in consequence of the
granting of this permit. Additionally, the applicant understands and will comply
with all non -point source regulations per the Cupertino Municipal Code, Section
Suture Date
bi 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 of the property, am exclusively contracting with licensed con;f 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 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
permit is issued.
I certify that in the performance of the work for which this permit is issued, I shall
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 exempti , I
become subject to the Worker's Compensation provisions of the Labor Code, must
forthwith comply with such provisions or this permit shall be deemed
APPLICANT CERTIFICATION
I certify that 1 have read this application and state that the above information is
,mt. I agree to comply with all city and county ordinances and state laws relating
ding construction, and hereby authorize representatives of this city to enter
upon the above entioned property for inspection purposes. (We) agree to save
indemnify and p harmless the City o Cupertino against liabilities, judgments,
costs, and expe es which may accrue st said City in consequence of the
granting of this t 4ditionally, th a plicant understands and will comply
with all non-po' sou regul tions p t Cupertino Municipal Code, Section
9.18. ftA � /
BUILDING PERMIT INFO: BLDG r— ELECT r— PLUMB r—
MECH r RESIDENTIAL r COMMERCIAL r
JOB DESCRIPTION: NEW SINGLE STORY SFDWL (2497SQ) W/ATTACHED
GARAGE
(515)-TREE PROTECTION REQUIRED. SANITARY IS
SUNNYVALE'S JURISDICTION.
Sq. Ft Floor Area: Valuation: $400000
APN Number: 37534039.00 1 Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
Issued bye Date:
RE -ROOFS:
All roofs shall be inspected prior to any roofing material being installed. If a roof is
installed without fast 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.
Addi nally, should I use equipment or devices which emit hazardous air
conta nants�as defined by th y Area Air Quality Management District I will
main t in compliance with the ertino Municipal Code, Chapter 9.12 and the
Healt & SNty Co*, *cqo 5503, 25533, and 25534.
• 1
I hereby Affirm that there is hcon5diction lending agency for the performance of work's
for which this permit is issuedWec. 3097, Civ C.)
Lender's Name
Lender's Address
ARCHITECT'S DECLARATION
Date
I understand my plans shall be used as public records.
Licensed Professional