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09040102 REV2 CITY OF CUPERTINO BUILDING PERMIT # 7/ BUILDING ADDRESS: I 1 I 1 MILKY WAY CONTRACTOR:TBD-TO BE DETE PERMIT NO:09040102 OWNER'S NAME: DANIEL HO DATE ISSUED:08/24/2009 n"'NER'S PHONE: 4083660606 PHONE NO: G LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ELECT r PLUMB License Class Lic.# MECH f— RESIDENTIAL f— COMMERCIAL Contractor Date JOB DESCRIPTION: ADD 1,606' I hereby affirm that I am licensed under the provisions of Chapter 9 PORCH,DECK,ENTRANCE,MASTERBEDBATH,WALK IN (commencing with Section 7000)of Division 3 of the Business&Professions CLOSET,ENTERTAINMNT,FAMILY,BATHRM,KTfCHEN,LAUNDRY.REMODEL 1,421'- Code and that my license is in full force and effect. GARAGE,LIVING,FAMILY,DINING RM,KITCHEN,3BEDRMS,2BATHRMS.NEW WINDOWS,SKYLIGHT,REROOF29 SQUARES. I hereby affirm under penalty of perjury one of the following two declarations: 12/16/09 REV#2,REVISE STRUCTURAL CEILING PLAN 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. Valuation:$200000 Sq.Ft Floor Area: APPLICANT CERTIFICATION 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 APN Number:36219012.00 Occupancy Type: 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 PERMIT EXPIRES IF WORK IS NOT STARTED granting of this permit. Additionally,the applicant understands and will comply WITHIN 180 DAYS OF PERMIT ISSUANCE OR with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION. Signature Date �G a Issued by• Date:(/� I I OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: RE-ROOFS: I,as owner of the property,or my employees with wages as their sole compensation, All roofs shall be inspected prior to any roofing material being installed.If a roof is will do the work,and the structure is not intended or offered for sale(Sec.7044, installed without first obtaining an inspection,I agree to remove all new materials for Business&Professions Code) inspection. I,as owner of the property,am exclusively contracting with licensed contractors to Signature of Applicant: Date: construct the project(Sec.7044,Business&Professions Code). I hereby affirm under penalty of perjury one of the following three ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER 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 HAZARDOUS MATERIALS DISCLOSURE performance of the work for which this permit is issued. I have read the hazardous materials requirements under Chapter 6.95 of the I have and will maintain Worker's Compensation Insurance,as provided for by California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain Section 3700 of the Labor Code,for the performance of the work for which this compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health& permit is issued. Safety Code,Section 25532(a)should I store or handle hazardous material. I certify that in the performance of the work for which this permit is issued,I shall Additionally,should I use equipment or devices which emit hazardous air not employ any person in any manner so as to become subject to the Worker's contaminants as defined by the Bay Area Air Quality Management District I will Compensation laws of California. If,after making this certificate of exemption,I maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the become subject to the Worker's Compensation provisions of the Labor Code,I must Health&Safety Code,Sections 25505,25533,and 25534. forthwith comply with such provisions or this permit shall be deemed revoked. Own thiarized agent: ( 2/ Date: © r APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is CONSTRUCTION LENDING AGENCY 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 I hereby affirm that there is a construction lending agency for the performance of work's upon the above mentioned property for inspection purposes.(We)agree to save for which this permit is issued(Sec.3097,Civ C.) indemnify and keep harmless the City of Cupertino against liabilities,judgments, Lender's Name cr nd expenses which may accrue against said City in consequence of the Lender's Address gi g of this permit.Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. _ ARCHITECT'S DECLARATION Signature - Date I O� I understand my plans shall be used as public records. 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