10080139CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 19387 SAKURA WAY
CONTRACTOR: ANTHONY HODDER
PERMIT NO: 10080139
CONSTRUCTION
OWNER'S NAME:
CUPERTINO, CA 95014
PHONE NO: (408) 257-4317
❑ LICENSED CONTRACTOR'S DECLARATION
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BUILDING PERMIT INFO: BLDG ELECT PLUMB
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License Class Lic. #T(n��
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MECH RESIDENTIAL COMMERCIAL
Contracto ateQ
I hereby affirm that I am licensed under the provisions of Chvt,;19
JOB DESCRIPTION: REMODEL 144 SQ Fr KITCHEN, 80 SQ FT BATH, REPLACE
(commencing with Section 7000) of Division 3 of the Business & Professions
10 RECEP, 30 FIXTURES ADD SKYLIGHTS, 3 WINDOW
Code and that my license is in full force and effect.
REPLACEMENT STRUCTURAL
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.
I have and will maintain Worker's Compensation Insurance, as provided for by
Sq. Ft Floor Area:
Valuation: $50000
Section 3700 of the Labor Code, for the performance of the work for which this
permit is issued.
APN Number: 37503015.00
Occupancy Type:
APPLICANT CERTIFICATION
I 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
to building construction, and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We) agree to save
PERMIT EXPIRES IF WORK IS NOT STARTED
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
costs, and expens ch may accrue against said City in consequence of the
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
granting of this Additionally, the applicant understands and will comply
180 DAYS FROM LAST CALLED INSPECTION.
with all non- mt so a regulations per the Cue o Municipal Code, Section
9.18. �- %� , dZd
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Issued by+o" � Date:
❑ OWNER -BUILDER DECLARATION
RE -ROOFS:
I 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 roof is
the following two reasons:
installed without first obtaining an inspection, I agree to remove all new materials for
1, 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
I hereby affirm under penalty of perjury one of the following three
declarations:
1 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 of the
performance of the work for which this permit is issued.
California Health & Safety Code, Sections 25505, 25533, and 25534. 1 will maintain
I have and will maintain Worker's Compensation Insurance, as provided for by
compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health &
Section 3700 of the Labor Code, for the performance of the work for which this
Safety Code, Section 25532(a) should I store or handle hazardous material.
permit is issued.
Additio ,should I use equipment or devices which emit hazardous air
conte na s as defined by the Bay Area Air Quality Management District I will
I certify that in the performance of the work for which this permit is issued, I shall
mai ain c mplian with the CTni ' al Code, Chapter 9.12 and the
not employ any person in any manner so as to become subject to the Worker's
He
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APPLICANT CERTIFICATION
CONSTRUCTION LENDING AGENCY
I certify that I have read this application and state that the above information is
I hereby affirm that there is a construction lending agency for the performance of 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 harmless the City of Cupertino against liabilities, judgments,
Lender's Address
costs, and expenses which may accrue against said City in consequence of the
granting of this permit. Additionally, the applicant understands and will comply
with all non -point source regulations per the Cupertino Municipal Code, Section
ARCHITECT'S DECLARATION
9.18•
I understand my plans shall be used as pubhc records.
Signature Date
Licensed Professional