10030162 CITY OF CUPERTINO BUILDINGPERMIT
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CONTRACTOR. ERMINED PERMIT NO:10030162
BUTI,DING ADDRESS: 10161 MACADAM LN DATE ISSUED:03/29/2010
MIS NAME: ENGELI GAGNI PHONE NO:
OWNER'S PHONE: 4084644601
LICENSED CONTRAC
TOR'S DECLARATION BUILDING PERMIT INFO: BLDG F ELECT F PLUMB
License Class C'-� Lie.#
tp��1 l MECH RESIDENTIAL COMMERCIAL
3��c�,/ () REMODEL 2 BATHS(NON 148SQ;JIM
69::--Date JOB DESCRIPTION: STRUCTURAL),
Contractor
I hereby a arm that I am licensed under the provisions of Chapter 9 WOLKCONSTRUCTION PD FOR BSL
(commenci g ith Section 7000)of Division 3 of the Business&Professions
Code and t 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. rovided for by Valuation:$24000
I have and will maintain Worker's Compensation Insurance,as p
Section 3700 of the Labor Code,for the performance of the work for which this Sq.Ft Floor Area:
permit is issued. Occupancy Type:
APPLICANT CERTIFICATION
APN Number:36901054.00
infoation is
I certify that I have read this a io and n ancntordinanehat the s and ate laws relating
correct.I agree to comply all city county
to building construction,tion a drhereby operty for nspectiorize representatives
purposes sof this city to(We)agree to aveenter
PERMIT EXPIRES IF WORK IS NOT STARTS
upon the above m p WITHIN 180 DAYS OF PERMIT IS
OR
indemnify and keep harmless the City df Cupertino against liabilities,judgments,
ence of the
costs,and expenses which may accrue against said City in understands and will comply 180 DAYS FROM LAST CALLED INSPECTION.
granting of this permit. Additionally,the app
with all non-point source regulations per the Cupertino Municipal Code,Section Date:
9.18. ���-,-�j /V Issued
P �"'1 Dates
.re
OWNER BUILDER DECLARATION
RE-ROOFS.
installed without first obtaining an inspection,I agree to remove all new materials for
I hereby
affirm that I am exempt from the Contractor's License Law for one oArooshall be inspected prior to any roofing material being installed.1 a roofis
f ll fs
the following two reasons:
or my employees with wages as their sole compensation, inspection. Date:
I,as owner of the property,
will do the work,and the structure is not intended or offered for sale(Sec.7044, Signature of Applicant:
Business&Professions Code)
I,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 HAZARDOUS MATERIALS DISCLOSURE
declarations:
I have and will maintain a Certificate of Consent to self-insure for Worker's I have read the hazardous materials requirements under Chapter 6.91 will oft e
Compensation,as provided for by Section 3700 of the Labor Code,for the California Health&Safety Code,Sections 25505 2553Chapter 9 12 andnd 4the Health&am
provided for by compliance with the Cupertino Municipal Code,
performance of the work for which this permit is issued.
I have and will maintain Worker's Compensation Insurance,as p Safety Code,Section 25532(a)should I store or handle hazardous material.
Additionally,should I use equipment or devices which emit hazardous air
Section 3700 of the Labor Code,for the performance of the work for which this Chapter 9.12 and the
contaminants as defined by the Bay Area Air Quality Management District I will
permit is issued.
subject to the Worker's Health&Safety Code,Sections 25505,25533,and 25534.
I certify that in the performance of the work for which ub permit is issued,I shall maintain compliance with the Cupertino Municipal Code,
not employ any person in any manner so as to becomes J
Owne or authpjzed� ��
ensation laws of C
become subject to the Worker's CompenC1Compalifornia. If,after making this certificate of exemption,I !! �I sation provisions of the Labor Code,I must Date:
forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY
APPLICANT CERTIFICATION I hereby affirm that there is a construction lending agency for the performance of work's
for which this permit is issued(Sec.3097,Civ C.)
I certify that I have read thisapplication
allcdo and counttY ordinances and state laws relating Lender's Name
correct.I agree to comply cityto
,ling construction,and hereby authorize this city agree to save enter
i. ne above mentioned property for inspection pure Lender's Address
indemnify and keep harmless the City of Cupertino against liabilities,judgments, ARCHITECT'S DECLARATION
costs,and expenses which may accrue against nant understands and will ty in consequence oomply
granting o this permit.Additionally,the app plans shall be used as public records.
with all non-point source regulations per the Cupertino Municipal Code,Section I understand my p
9.18.
Date-- -
Licensed Professional
Signature