13060034I CITY OF CUPERTINO BUILDING PERMIT I
BUILDING ADDRESS: 10591 S BLANEY AVE CONTRACTOR: RICHARD MAK PERMIT NO: 13060034
OWNER'S NAME: RICHARD MAK
OWNER'S PHONE: 4084647270
❑ LICENSED CONTRACTOR'S DECLARATION
License Class Lic.#
Contractor Date
I hereby affirm that I am licensed under the provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business & Professions
Code and that my license is in full force and effect.
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
Section 3700 of the Labor Code, for the performance of the work for which this
permit is issued.
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
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
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
9.18.
Signature,
Date
OWNER- BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons:
I, 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)
I, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec.7044, Business & Professions Code).
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
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.
I certify that in the performance of the work for which this permit is issued, I shall
not employ any person in any manner so as to become subject to the Worker's
Compensation laws of California. If, after making,this certificate of exemption, I
a.
become subject to the Worker's Compensation provisions of the Labor Code, I must
forthwith comply with such provisions or this pert nit shall be deemed revoked.
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
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
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 regula 'on th
er e Cupertino. Municipal Code, Section
9.18. R
Signature Date U51(3
10591 S BLANEY AVE I DATE ISSUED: 06/05/2013
CUPERTINO, CA 95014 -4542 1 PHONE NO:
JOB DESCRIPTION: RESIDENTIAL
CHANGE SIZE & REPLACE 1 (E)SLIDING DOOR &
REMOVE &
REPLACE 1 (E) SLIDING DOOR, SAME SIZE. BOTH DOORS
TO BE FRENCH DOORS. ADD 8 (N) RECESSED LIGHTS (2
Sq. Ft Floor Area: I Valuation: $8000
I APN Number: 36933004.00 I Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS O + ERMIT ISSUANCE OR
180 DAYS F CALLED INSPECTION.
yate:
: D
RE- ROOFS:
All roofs shall be inspected prior to any roofing material being installed. If a roof is
installed without first obtaining an inspection, I agree to remove all new materials for
inspection.
Signature of Applicant: Date:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
HAZARDOUS MATERIALS DISCLOSURE
I have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533, and 25534. I will
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
Health & Safety Code, Section 25532(x) should I store or handle hazardous
material. Additionally, should I use equipment or devices which emit hazardous
air contaminants as defined by the Bay Area Air Quality Management District I
will maintain compliance with the Cupertino Munici al Code, Chapter 9.12 and
the Health &Safety e, �55,25533,a 25534. Owner or authorized agen ate: l
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of
work's for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
Lender's
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Licensed Professional
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT - BUILDING DIVISION
10
10300 TORREAVENUE • CUPERTINO, CA 95014-3255
(4Q8) .777-3228 • FAX (408 ) 777-3333 • building5cuperfino.orn
M- wizwt�,(wt-rRT-7r- . "AV rl ATITIM(N. M ATTPPA-r1nW/-ff 1 1
PROJECT
AFN #
OWNERNAME
-K1c14Ag;D: M-A<
Px0 r1
&MA-1L1_jC Am a k (g YaA 06 - C00"I
ST?JMTA PDRES$
CITY, STATE, ZIP iq
FAX
CONTACT NAME
PHOM-t
F-MAIL
STREET ADDRESS'.
CITY, STATE, ZIP
FAX
OWNER ❑ ow'NER B=ER ❑ owNERAGmT ❑ CONTRACTOR ❑coNTRAcToRAawr ❑ ARCHIISCT ❑E14GNEER ❑ DEVELOPER 13TENANT
CONTRACTOR NAME �-JA:50(-,] 10OLaqb, I
LICENSE NUMBER /2(fi(906�;
F7SET7E
BUS. UC #
COMPANY NAM`t4&Ed 516',Q96 4C 1,Dql
r
E-MAIL
FAX
FrREETADDRESS6761 040(g6-1C,
CITY, STATE, ZWXt
4V
_r _ 9�-?l
-36)
ARCHITECT040WEER NAME
LICENSE NUMBER
BUS. LIC #
COMPANY NAME
E-MAIL
FAX
STREET ADDRESS
CITY, STATE, ZIP
PHONE
DESCRIPTION OF WORK
Dr n
PA- 710 v
-TD C�I-ng6 "XL7gp i*AiAPP 10-Ge(Ek-0
2, i >
EXISTING USE,
PROPOSED WE
CONSTIL TYPE
4 STORMS
USE
TYPE
Occ.
SQ-FT.
VALUATION (S)
Ex[STG
NEW FlOOR
DEMO
TOTAL
AREA
AREA
AREA
NErAREA
BATHROOM
KITCBEN OTHER
REMODEL AREA
REMODILARPA REMODELAREA
.PORCH AREA
DECK AREA TOTAL DECKIPORCH AREA
I GARAGE AREA: DETACH
ATTACH
DWILLING s:1
IS A SWWW UM YW�
BEING AbDED? ONO
SECOND STORY OYES
ADDMON? 13NO
.PRE - APPLICATION []YES IF YES, PROVIDE COPY OF
IS THE BLDG AN ❑ YES
"bm
PLANNNG APPL 41 [3WO PLANNB40 APPROVALIETTER.
EICHLERHOME? 13 NO
By my signature below, I certify to each of the following: I am the property owner or authorized agent t<nat—lffe- property owner's behalf. I have read this
'0 is correct I v; the Description of Work and verify it is accurate. I agree to comply with all applicable low
application and the information I "M
4havvided
u �Teid
ordinances and state la tiara. uthorize representatives of Cupertino to enter the d for inspection purposes.
. = I v1 7i
i ture ofApplicwWAge!jt Date
S gna' 4. - 2n==
.SUPPLEMENTAL INFORMATI014 REQUIRED -
in
New SFD or-Multifamily dwellings: Apply for demolition permit for
existing building(s);..Demolition permit is required prior to issuance of building
p6rmit for new building.
Commercial Bldgs-, Provide a completed Hazardous Materials Disclosure
form if any Hazardous Materials are being used as part ofthis project.
Copy of larming Approval Letter or Meeting with Planning prior to
submittal of Building Permit application.
BldgApp_,201 L doc revised 061x'1/11
CITY OF CUPERTINO
1��,� �
FFV FCTTMATOR — RITTI,DING DIVISION
Mech. Plan Check Phanb. Plan Check Elec. Plan Check 10.0 1 hrs $0.00
:lfech. Permit Fee: Plumb. Permit Fee: Elec. Permit Fee: IEPERMIT
Other Alech. Imp. Ocher Plumb Insp. Other Elec. Insp. 0.0 s$45.00
lrtech. Ins 1'ee: Plumb, f;�sp. Fee: Elec. Ins. f'ee:
NOTE: This estimate does not include fees due to other Departments (Le. Planning, Public Works, Fire, Sanitary Sewer District, School
ADDRESS: 10591 S BLANEY AVE
DATE: 06/05/2013
REVIEWED BY: MELISSA
FEE
APN: 369 33 004
BP #:
*VALUATION: 1$8,000
*PERMIT TYPE: Building Permit
PLAN CHECK TYPE: Alteration / Repair
PRIMARY
USE: SFD or Duplex
Suppl. PC Fee: Reg. Q OT
PENTAMATION
PERMIT TYPE: 1GENRE i
WORK
CHANGE SIZE & REPLACE 1 E PATIO DOOR & REMOVE & REPLACE 1 E FRENCH DOOR
SCOPE I
LIKE FOR LIKE. ADD 8 (N) RECESSED LIGHTS (2 IN BATH, 3 IN KITCHEN, 2 IN LIVING RM & 1 INS
Mech. Plan Check Phanb. Plan Check Elec. Plan Check 10.0 1 hrs $0.00
:lfech. Permit Fee: Plumb. Permit Fee: Elec. Permit Fee: IEPERMIT
Other Alech. Imp. Ocher Plumb Insp. Other Elec. Insp. 0.0 s$45.00
lrtech. Ins 1'ee: Plumb, f;�sp. Fee: Elec. Ins. f'ee:
NOTE: This estimate does not include fees due to other Departments (Le. Planning, Public Works, Fire, Sanitary Sewer District, School
District, etc). These ees are based on the relfmina
in ormation available and are onl an estimate. Contact the De t or addn'l in o.
FEE ITEMS (Fee Resolution 11 -053 E . 7/U121
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee:
$0.00
=
# Window / Sliding Glass Door
Suppl. PC Fee: Reg. Q OT
0.0
hrs
$0.00
$400.00
IWINREP
Replacement
PME Plan Check:
$0.00
8
Electrical
Permit Fee:
$0.00
$67.00
IBREwMT
Fixtures, Lighting
Suppl. Insp. Fee-0 Reg. Q OT
0,0
hrs
$0.00
PME Unit Fee:
$0.00
PME Permit Fee:
$45.00
(:onswitclion Tax
Administrative Fee: IADMIN
$42.00
Work Without Permit? ® Yes (E) No
$0.00
E)
Advanced Planning Fee;
$0.00
Select a Non - Residential 0
Travel Documentation Fee: 1TRAVDOC
$45.00
Building or Structure
Strom Motion Fee: 1BSEISMICR
$0.80
Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC
$1.00
$133.801 $467.00 m e� $600.80
• Revised: 04/29/2013
C�
CUPEftTINO
OWNER - BUILDER DISCLOSURE FORM
COMMUNITY DEVELOPMENT DEPARTMENT - BUILDING DIVISION
10300 TORRE AVENUE - CUPERTINO, CA 95014 -3255
(408) 777 -3228 - FAX (408) 777 -3333 - buildinaCcr?cupertino.org
Dear Property Owner(s):
An application for a building permit has been submitted in your name listing yourself as the builder of the property
improvements specified at:
SITEADDRES3Z� �fR A6
T t
APN�6Q ��� ob� BP#
/
OWNER NAME ! i^y
ff l�Acr—
OWNER ADDRESS I A4d �/)
t�N7CT
DESCRIPTION OF. WORK:. L#. Z f{ �j -643 2<
We . are providing you with an Owner- Builder Acknowledgment and Information Verification Form to make you aware' of
your responsibilities and possible risk you may incur by having this permit issued in your name as the Owner - Builder. We
will not issue a building permit until you have read, initialed your understanding of each provision, signed, and
returned this form to us at our official address indicated. An agent of the owner cannot execute this notice unless
you, the property owner, obtain the prior approval of the permitting authority.
OWNER'S ACKNOWLEDGMENT AND VERIFICATION OF INFORMATION
(DIRECTIONS: Please read and initial each statement below to signify you understand or verify this information.)
V 1. 1 understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner
Builder" building permit that erroneously implies that the property owner is providing his or her own labor and material
personally. 1, as an Owner - Builder, may be held liable and subject to serious financial risk for any injuries sustained by
an unlicensed person and his or her employees while working on my property. My homeowners insurance may not
provide coverage for those injuries. I am willfully acting as an Owner - Builder and am aware of the limits of my
insurance coverage for injuries to workers on my property.
V2. I understand building permits are not required to be signed by property owners unless they are responsible for
the construction and are not hiring a licensed Contractor to assume this responsibility.
V 3. 1 understand as an. "Owner - Builder" I am the responsible party of record on the permit. I understand that. l *may
protect myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her
name instead of my own.
✓4. I understand Contractors are required by law to be licensed and bonded in California and to list their license
numbers on permits and contracts.
V5. I. understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the
total value of my construction is at least five hundred dollars ($500), including labor and materials, I may be
considered. an. "employer" under state and federal law.
V / 6. 1 understand 'if I am considered an "employer" understate and federal law, I must registerwith the state and
federal government, Withhold payroll taxes, provide workers' compensation disability insurance, and contribute to
unemployment compensation for each "employee." I also understand my failure to abide by these laws may subject
me to serious financial risk.
',/7. 1 understand under California Contractors' State License Law, an Owner - Builder who builds single - family
residential structures cannot legally build them with the intent to offer them for sale, unless all work is performed by
licensed subcontractors and the number of structures does not exceed four within any calendar year, or all of the work
is performed under contract with a licensed general building Contractor.
8. 1 understand as an Owner - Builder if I sell the property for which this permit is issued, I may be held liable for
any financial or personal injuries sustained by any subsequent owner(s) that result from any latent construction
defects in the workmanship or materials.
OwnerBuilderF'orm 2010.doc revised 04114110
iA. I understand I may obtain more information regarding my obligations as an °employer" from the Internal
Revenue Service, the United States Small Business Administration, the California Department of Benefit Payments,
and the California Division of Industrial Accidents. I also understand I may contact the California Contractors State
License Board (CSLB) at 1- 800 - 321 -CSLB (2752) or www.cslb.ca.gov for more information about licensed
contractors.
10. 1 am aware of and 'consent to an Owner - Builder building permit applied for in my name, and understand that
am he parry legally and financially responsible for proposed construction activity at the site address listed above.
11. 1 agree that, as the party legally and financially responsible for this proposed construction activity, I will abide
by call applicable laws and requirements that govern Owner - Builders as well as employers.
V 12: 1,agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the
information I. have provided on .this form. Licensed contractors are regulated by laws designed to protect the public. If
you contract with-someone who does not have a license, the Contractors' State License Board may be unable to
assist you With -any financial loss you may sustain as a result of a complaint. Your only remedy against unlicensed
Contractors may be in civil court. It is also important for you to understand that if an unlicensed Contractor or
employee of that individual or firm is injured while working on your property, you may be held liable for damages. If
you obtain a permit as Owner- Builder and wish to hire Contractors, you will be responsible for verifying whether or not
those Contractors are properly licensed and the status of their workers' compensation insurance coverage.
CONSTRUCTION LENDING AGENCY
(DIRECTIONS: please complete the following construction lending agency information.)
I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued
(Sec 3097 Civ.).
Lender Name:
Lender Address:
Before a building permit can be issued, this form must be completed and signed by the property owner and
returned to the agency responsible for issuing the permit. Note: A copy of the property owner's driver's license,
form notarization, or other verification acceptable to the c'ty ay be required to be presented when the permit is issued
to verfy the property owner's signaf .
Property Owner's Signature:
Date:
- -- - - - - - -- - - - - -- - -- - - - - - -- ---------------------------------------------------------------------------------------------------------
(NOTE: The following Authorization Form is required to be completed by the property owner only when designating an
agent of the property owner to apply for a construction permit for the Owner - Builder).
AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF
Excluding the Notice to Property Owner, the execution of which I understand is my personal responsibility, I hereby.
authorize the following person(s).to act as my agent(s) to apply for, sign, and file the documents necessary to obtain an
Owner - Builder Permit for my project.
Scope of Construction Project (or Description of Work):
Project Location or Address:
Name of Authorized Agent:
Tel No
Address of Authorized Agent:
I declare under penalty of perjury that I am the property owner for the address listed above and I personally filled out the
above information and certify its accuracy. Note: A copy of the property owner's driver's license, form notarization, or other
verification acceptable to the city may be required to be presented when the permit is issued to verify the property owner's
signature.
Property Owner's Signature:
Date:
OwnerBuilderForm 2010.doc revised 04114110
JOB ADDRESS: { Z UL— .
PERMIT # 3 D d a?
OWNER'S NAME:
PHONE #
GENERAL CONTRACTOR: E
BUSINES&LXCENSE #
ADDRESS:
CITY/ZIPCODE :.�
*Our municipal code requires all businesses working in the city to have,a City of Cupertino °:business license.
NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE
GENERAL CONTRACTOR AND ALL SUBCONTRACTORS HAVE OBTAINED A`:;CITY OF CUPERTINO
BUSINESS LICENSE.
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following information
✓ SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets & Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring / Carpeting
Linoleum / Wood
Glass / Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Painting / Wallpaper _
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner / Contractor Signature Date
C
BU
JUN 05
REVIEWED FOR CODI
Reviewed By. r,,
34" 60"-�
28"
Bedroom
Bath
Bath
Department
kNS roe
0
BedrM"et of p
job site duf
chang,
therefrom,
The stampir
be held toi
Living Roan
Kitchen
51-dity Ordinanf e or State Law. Garage
2
P(C w4'o PAS
w;qk S. 9L*Jz(
.:::CA Pr- avrjo(aA 15,01Y
04"2 6�' 3 3 - 66 4
Scope of Work
1. Replace two patio
doors.
2. Extend walls to
close off master
bath area.
Sheetrock and
stucco. Add interior
door.
3. Add new lights.
ipLoT 'PLANS
CMCKED By
0
IMI,y)G. DVPT-
0
UNITY DRIELOilMOIT
Q612
4RTMENT
JILDING DIVISION - CUPER
NNO
APPROVED
ns and specifications MU
ST be kept at the
g construction. It is un1w
iful to make any
or alterations on same, c
r to deviate
fithout approval from the
'J""O" from
3uilding Official.
of this plan and . ecifica:ions
SHALL NOT
approva.
n ppi
of the violation
51-dity Ordinanf e or State Law. Garage
2
P(C w4'o PAS
w;qk S. 9L*Jz(
.:::CA Pr- avrjo(aA 15,01Y
04"2 6�' 3 3 - 66 4
Scope of Work
1. Replace two patio
doors.
2. Extend walls to
close off master
bath area.
Sheetrock and
stucco. Add interior
door.
3. Add new lights.
ipLoT 'PLANS
CMCKED By
0
IMI,y)G. DVPT-
0
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10591 S BLANEY AVE
CONTRACTOR: GREEN ENGINEERED
PERMIT NO: 13060034
STONE
OWNER'S NAME: RICHARD MAK
551 LARNEGIE
DATE ISSUED: 06/05/2013
OWNER'S PHONE: 4084647270
MANTECA, CA 95337
PHONE NO: (209) 249 -8628
❑ LICENSED CONTRACTOR'S DECLARATION
JOB DESCRIPTION: RESIDENTIAL IJ COMMERCI4,1,1
License Class Lic. # ! 7 7i Z'
CHANGE SIZE & REPLACE 1 (E)SLIDING DOOR &
Contractor &4459V &4459V S/nNEM/SF Date g ' j� �
REMOVE &
REPLACE 1 (E) SLIDING DOOR, SAME SIZE. BOTH DOORS
I hereby affirm that I am licensed under the provisions of Chapter 9
TO BE FRENCH DOORS. ADD 8 (N) RECESSED LIGHTS (2
(commencing with Section 7000) of Division 3 of the Business & Professions
Code and that my license is in full force and effect.
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
Sq. Ft Floor Area:
Valuation: $8000
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
APN Number: 36933004.00
Occupancy Type:
permit is issued.
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is
PERMIT EXPIRES IF WORK IS NOT STARTED
correct. I agree to comply with all city and county ordinances and state laws relating
WITHIN 1 0 DAYS OF PERMIT ISSUANCE OR
to building construction, and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We) agree to save
180 DAY M LAST CALLED INSPECTION.
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
costs, and expenses which may accrue against said City in consequence of the
p
Issued by: Date: p .l10� 13
granting of this permit. Additionally, the applicant understands and will comply
with all non -point source regulations the C pertino Municipal Code, Section
9.18.
(�
RE- ROOFS:
Sig Date
All roofs shall be inspected prior to any roofing material being installed. If a roof is
installed without first obtaining an inspection, I agree to remove all new materials for
inspection.
❑ OWNER- BUILDER DECLARATION
Signature of Applicant: Date:
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
I, 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)
I, as owner of the property, am exclusively contracting with licensed contractors to
HAZARDOUS MATERIALS DISCLOSURE
construct the project (Sec.7044, Business & Professions Code).
I have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533, and 25534. I will
I 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 maintain 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 I
performance of the work for which this permit is issued.
will maintain compliance with the Cupertino Municipal Co e, Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance, as provided for by
the Health & Safety Code, Sections 2550y,,:95 nd 2 4.
Section 3700 of the Labor Code, for the performance of the work for which this
Owner or authorized a Date:
permit is issued.
I certify that in the performance of the work for which this permit is issued, I shall
not employ any person in any manner so as to become subject to the Worker's
CONSTRUCTION LENDING AGENCY
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
I hereby affirm that there is a construction lending agency for the performance of
forthwith 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
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
ARCHITECT'S DECLARATION
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
costs, and expenses which may accrue against said City in consequence of the
I understand my plans shall be used as public records.
granting of this permit. Additionally, the applicant understands and will comply
with all non -point source regulations per the Cupertino Municipal Code, Section
Licensed Professional
9.18.
Signature Date
Bath
L-OOM
Bedroom I Bedroom
'R W- L 3 0 6 0 c)3 V
Patio Door Landings: Deck & Pavers Step Richard Mak
10591 S. Blaney Ave.
Cupertino, CA 95014
(Deck & Pavers Step Elevations: 18") i 96" APN: 369-33-004
�Wj Pavers -I*— jo,
Living Room Dining Rbom
CUPE
RUildina E
aEV�&WEI)r'OR CODE COP
Reviewed By:
Kitchen
NO
tment
CE Garage
DEC 18 2013
bly.-