09100052 REV1 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10928 SYCAMORE DR CC NTRACI'OR:DJB PERMIT NO:09100052
CONSTRUCTION CO INC
ONVNER'S NAME: ROY&ANDREA HONG 14425 BIG BASIN WAY DATE ISSUED: 11/18/2009
OWNER'S PHONE: 6503909202 S/,RATOGA,CA 95070 PHONE NO:(408)867-2827
LICENSED CONTRACTOR'S DECLARATION r r r
/ BI.ILDING PERMIT INFO: BLDG ELECT PLUMB
License Class Lic.# (� C/o—) r v r r
/ �\ \ MECH RESIDENTIAL COMMERCIAL
Contractor �� _( fes]j, l- .6 to / 1( r (�
1 herebyaffirm that I am licensed under the provisions of ha ter/9 JC B DESCRIPTION: ADD 552'-GREAT ROOM,BREAKFAST NOOK&COVERED
p p PC RCHES TO THE REAR GUEST ROOM EXTENDED AT THE
(commencing with Section 7000)of Division 3 of the Business&Professions SIDE OF THE REAR,STRUCTURAL;REMODEL 501'KITCHEN
Code and that my license is in full force and effect.
5/:!4/2010-REVISION#1-EXTEND COVERED PORCH AREA
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. Sq.Ft Floor Area: Valuation:$150000
1 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 AI'N Number:34256037.00 Occupancy Type:
permit is issued.
APPLICANT CERTIFICATION
1 certify that I have read this application'and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED
correct. 1 agree to comply with all city and county ordinances and state laws relating WITHIN 180 DAYS OF PERMIT ISSUANCE OR
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save 180 DAYS FROM LAST CALLED INSPECTION.
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the Date:
granting of this permit. Additionally,the applicant understands and will comply Issued by:
with all non-point source regulations per the Cupertino Municipal Code,Section _
9.18. G_ IJ
RE-ROOFS:
,�n
iR" trature Date 6 A I roofs shall be inspected prior to any roofing material being installed.If a roof is
in stalled without first obtaining an inspection,I agree to remove all new materials for
in spection.
❑ OWNER-BUILDER DECLARATION
Signature of Applicant: Date:
1 hereby affirm that 1 am exempt from the Contractor's License Law for one of
the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
1,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)
1,as owner of the property,am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE
construct the project(Sec.7044,Business&Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the
C alifornin Health&Safety Code,Sections 25505,25533,and 25534. I will
I hereby affirm under penalty of perjury one of the following three n aintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
declarations: F ealth&Safety Code,Section 25532(a)should 1 store or handle hazardous
I have and will maintain a Certificate of Consent to self-insure for Worker's n iaterial. Additionally,should I use equipment or devices which emit hazardous
Compensation,as provided for by Section 3700 of the Labor Code,for the a,r contaminants as defined by the Bay Area Air Quality Management District I
performance of the work for which this permit is issued. M ill maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by th2ner
alth&Safety Code,Sections 25505,25533,and 25534.
Section 3700 of the Labor Code,for the performance of the work for which this C or authorized agent: Date:
permit is issued.
I certify that in the perlixmance 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 exemption,I CONSTRUCTION LENDING AGENCY
become subject to the Woi kcr's Compensation provisions of the Labor Code,1 must 1 hereby affirm that there is a construction lending agency for the performance of
forthwith comply with such provisions or this permit shall be deemed revoked. %,ork's for which this permit is issued(Sec.3097,Civ C.)
Lender's Name
APPLICANT CERTIFICATION Lender's Address
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 const ruction,and hereby authorize representatives of this city to enter
~)n the above mentione 1 property for inspection purposes.(We)agree to save ARCHITECT'S DECLARATION
mnify and keep hari ss the City of Cupertino against liabilities,judgments,
.,its,and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records.
granting of this permit.Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section licensed Professional
9.18.
Signature ____ Date