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09070180CITY OF CUPERTIN O BUILDING PERMIT BUILDING ADDRESS: 10576 LA RODA DR CONTRACTOR: NORTH CURRENT PERMIT NO: 09070180 BUILDERS O. R'S NAME: :;AN JOSE, CA 95119 PHONE NO: (408) 892-0071 LICENSED CONTRACTOR'S DECLARATION ELECT r— PLUMB r —9 ��� ''��� 3UILDING PERMIT INFO: BLDG License Class Lic. # �1D� � � ``,, ��'/� MECH RESIDENTIAL COMMERCIAL Contractor Ivp� ate hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:RMV EXISTING MASONRY FIREPLACE& INFILL, (commencing with Section 7000) of Division 3 of the Business & Professions vlAfNTAfN Code and that my license is in full force and effect. 3TRUCTRL INTEGRITY @FIREPLACE. RMOVE DOUBLE 5 SOCKET DOOR& UPSET 4X12 BEAM, INSTALL NEW GAS LINE 1 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 :iq, Ft Floor Area: Valuation: $12000 Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. APPLICANT CERTIFICATION ,CPN Number: 36933020.00 Occupancy Type: 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 expenses which may accrue against said City in consequence of the WITHIN 180 DAYS OF PERMIT ISSUANCE OR granting of this permit. Additionally, the applicant understands and will comply 180 DAYS FROM LAST CALLED INSPECTION. with all non -point source regulations er the Cupertino Municipal Code, Section 9.18. Si ;re Date--' Issued bye`�� Date: 7 - -2 7-cC ----- ` �= f— ❑ OWNER -BUILDER DECLARATION 1 hereby affirm that I am exempt from the Contractor's License Law for one of RE -ROOFS: k1l roofs shall be inspected prior to any roofing material being installed. If a roof is the following two reasons: nstalled 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, nspection. will do the work, and the structure is not intended or offered for sale (Sec.7044, Business & Professions Code) signature of Applicant: Date: 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 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 of the performance of the work for which this permit is issued. -alifornia Health & Safety Code, Sections 25505, 25533, and 25534. 1 will maintain 1 have and will maintain Worker's Compensation Insurance, as provided for by :ompliance 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 1 store or handle hazardous material. permit is issued. %dditionally, should I use equipment or devices which emit hazardous air =ontaminants as defined by the Bay Area Air Quality Management District 1 will 1 certify that in the performance of the work for which this permit is issued, 1 shall maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the not employ any person in any manner so as to become subject to the Worker's health & Safety Code, Sections 25505, 25533, and 25534. Compensation laws of California. If, after making this certificate of exemption, I become subject to the Worker's Compensation provisions of the Labor Code, I must �['�►/ APPLICANT CERTIFICATION CONSTRUCTION LENDING AGENCY I certify that I have read this application and state that the above information is hereby affirm that there is a construction lending agency for the performance of work's c, I. I agree to comply with all city and county ordinances and state laws relating or which this permit is issued (Sec. 3097, Civ C.) .ling construction, and hereby authorize representatives of this city to enter Lender's Name 4"i 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• understand my plans shall be used as public records. Signature Date Licensed Professional