09090031 I _ CITY OF CUPERTINO BUILDING PERMIT
.k0DRESS: 10310 BEARDON DR CONTRACTOR:TBD-TO BE PERMIT NO:09090031
l DETERMINED
: ,R'S NAME: BEN & CHRISTINE ELLIS DATE ISSUED:09/04/2009
OWNEWS PHONE: 408?034910 PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION r— T_ r
BUILDING PERMIT[NFO: BLDG ELECT PLUMB
Ucei,.e Class_____ Lia#� _ _
MECH RESIDENTIAL COMMERCIAL
Contractor _ _Date
I hereny affirm that 1 am licensed under the provisions of Chapter 9 JOB DESCRIPTION: ADD 227 SQ FT TO ATTACHED GAR-AG ?
(commencing with Section 7000)of Division 3 of the Business&Professions ADD CANOPY OVER,Ae&,)�VO/I,vLLG�.Sj SKL-%lS
Code and that my license is in full force and effect. FRONT DOOR /6?llf,e(,tnG'
1 hereby affirm under penalty of perjury one of the following two declarations:
I hay.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•,pork for which this permit is issued. Sq.Ft Floor Area: Valuation:$10000
1 have and will maintain!Wirker's Compensation Insurance,as provided for by
Section 3700 of the LaEor Code,for the performance of the work for which this
APN Number-32633020.00 Occupancy Type:
permit is issued.
APPLICANT CERTIFICATION
I certity that I have read this appl cation and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED
corre:;t. I agree to a„npiy with all city and county ordinances and state laws relating WITHIN 180 DAYS OF PERMIT ISSUANCE OR
to builtiing 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.
in6e.rrnify aid keep harmless the City of Cupertino against liabilities,judgments,
,:gists,and expenses which may accrue against said City in consequence of the
Date:
granti.,g of this permit. Additionally,the applicant understands and will comply Issued by:_ _
with ail non-point source regulations per the Cupertino Municipal Code,Section
RE-ROOFS:
azure__- Dat I sp ed prior to any roofing material being installed.If a roof is
talle out first obtaining an inspection,I agree to remove all new matztials for
OWNER-BUILDER DECLA
i D
ipplicant: Date:
1 hereby affirm that I am exempt from the Contractor's Lie use La 0`1
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 )caner of the property,am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE
consinact the project(Sec 7044,Business&Professions Coue). 1 have read the hazardous mater ials requirements under Chapter 6.95 of the
California Health&Safety Code,Sections 25505,25533,and 25534. 1 will
1 hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
declarations: Health&Safety Code,Section 25532(a)should I store or handle hazardous
I have and will maintaii a Certificate of Consent to self-insure for Worker's material. Additionally,should I use equipment or devices which emit hazardous
Compensation,as provided for by Section 3700 of the Labor Code,for the air contaminants as defined by the Bay Area Air Quality Management District 1
performance of the work for which this permit is issued. will maintain compliance with the Cu er' o Vunicipal Code,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Secti 2 534. —71-0a Stiction 3700 of the Labor Code,for the performance of the work for which this
permit is issued. Owner or authorized agent: Date: d
I certify that in the performance of the work for which this permit is issued,I shall
not employ any person is any manner so as to become subject to the Worker's
Compensation laws oCalifornia. If,after making this certificate of exemption,I CONSTRUCTION LENDING AGENCY
f
become subject to the Worker's Compensation provisions of the Labor Code,I must I hereby affirm tha!there is a construction lending agency for the performance of
forth.vith comply with such provisions or this permit shall be deemed revoked. work's for which this permit is issued(Sec.3097,Civ C.)
Lender's Name
APPLICANT CERTIFICATION Lender's Address
1 certify that 1 have read this application and state that the anove information is
ct. I agree to compl�with all city and county ordinances and state laws relating
;ilding construction.and hereby authorize representatives of this city to enter
.:;,.A,the above mentioned property for inspection purposes (We)agree to save
ARCHITECT'S DECLARATION
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses whi-.h may accrue against said City in consequence of the I understand my plans shall be used as public records. q
granting of this permit.Additionally,the applicant understands and will comply
with•all non-poi so,rce guhations per he Cupertino Municipal Cod Sect' Licensed Professional II
9.18. i
Signature X _ -----Date-'