09120042CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 7425 ROLLINGDELL DR
CONTRACTOR: G.S. CONSTRUCTION
PERMIT NO: 09120042
OWNER'S NAME:
SAN JOSE, CA 95124
PHONE NO: (408) 705-536$
❑ LICENSED CONTRACTOR'S DECLARATION
LARATION
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6 License Class Lic.
(J # �� ! �
BUILDING PERMIT INFO: BLDG ELECT PLUM
MECH I— I— RESIDENTIAL COMMERCI,
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Contractor Date 3 Laa n
1 hereby affir that 1 am ice u the provisions of Chapter 9
JOB DESCRIPTION: ADD 906 SQ FT TO FAMILY, KITCHEN, M.BATH
(commencing wt ision 3 of the Business & Professions
BEDROOM, 42 SQ FT TO FRONT PORCH, 96 SQ FT TO
Code and that my license is i u force and effect.
DECK, REMODEL 50 SQ FT TO EXISTING, NEW WATER
I hereby affirm tinder 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.
I have and will maintain Worker's Compensation Insurance, as provided for by
Sq. Ft Floor Area:
Valuation: $230000
Section 3700 of the Labor Code, for the performance of the work for which this
permit is issued.
APPLICANT CERTIFICATION
APN Number: 35932004.00
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
upon the above mentioned operty for inspection purposes. (We) agree to save
PERMIT EXPIRES IF WORK IS NOT STARTED
indemnify and keep harmle the of Cupertino against liabilities, judgments,
costs, and expenses which y c against said City in consequence of the
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
granting of this permit, dd io ally, the applicant understands and will co p►y
180 DAYS FROM LAST CALLED INSPECTION.
with all non point source fat ns r the Cupertino Municipal Code, Se ion
9.18.
by: Date: �!l
Signature Date 3 v
Issued
❑ OWNER -BUILDER DECLARATION
RE -ROOFS:
hereby affirm that I am exempt from the Contractor's License Law for one of
All roofs shall be inspected prior to any roofing material being installed. If a rO4
f is
the following two reasons:
installed without first obtaining an inspection, 1 agree to remove all new materii
Is for
I, as owner of the property, or my employees with wages as their sole compensation,
inspection.
will do the work, and the structure is not intended or offered for sale (Sec.7044,
Business & Professions Code)
Signature of Applicant: Date:
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
1 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
HAZARDOUS MATERIALS DISCLOSURE
Compensation, as provided for by Section 3700 of the labor Code, for the
I have read the hazardous materials requirements under Chapter 6.95 oft
e
performance of the work for which this permit is issued.
California Health & Safety Code, Sections 25505, 25533, and 25534. 1 will
aintain
I have and will maintain Worker's Compensation Insurance, as provided for by
compliance with the Cupertino Municipal Code, Chapter 9.12 and the Hes,th
&
Section 3700 of the Labor Code, for the performance of the work for which this
Safety Code, Sec 'on 25532(a) should I store or handle hazardous material.'
permit is issued.
Additionally, sho 1 1 u e quipment or devices which emit hazardous air
contaminants s e e by he Bay Area Air Quality Management District
1 will
I certify that in the performance of the work for which this permit is issued, I shall
maintain com is c w th th Cupertino Municipal Code, Chapter 9.12 anf
the
not employ any person in any manner so as to become subject to the Worker's
Health & Safe ectio s 25505, 25533, and 25534.
Compensation laws of California. If, after making this certificate of exemption, 1
become subject to the Worker's Compensation provisions of the Labor Code, I must
Owner
O
APPLICANT CERTIFICATION
CONSTRUCTION LENDING AGENCY
I certify that I have read this application and state that the above information is
1 hereby affirm that there is a construction lending agency for the performance
f work's
correct. 1 agree to comply with all city and county ordinances and state laws relating
for which this permit is issued (Sec. 3097, Civ C.)
to building construction, and hereby authorize representatives of this city to enter
Lender's Name
upon the above mentioned property for inspection purposes. (We) agree to save
indemnify and keep less the City of Cupertino against liabilities, judgments,
Lender's Address
costs, and expenses is may true against said City in consequence of the
granting of this pe i A iti a y, the applicant understands and will comply
with all non -point
Date 3 jD
Licensed Professional
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