15050153 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 1 185 CRESTLINE DR CONTRACTOR:TBD-TO BE PERMIT NO: 15050153
DETERMINED
OWNER'S NANU.: NORMA CLARK DATE. ISSUED:05/26/2015
OWNER'S PHONE: PHONE NO:
0 LICENSIED CONTRACTOR'S DECLARATION
BUILDING PEWMITINFO- 131,DG ELECT PLIA113
License Class Lic.9 F I—
INIFC11 RFSIDENTIAL COMMERCIAL
Contractor Date JOB DESCRIPTION RE-ROOI:22SQRSPEAR OI'I:/Rl:['LACI:Wi'l'lI
Sl IINGU�.S-CLASS A
I hereby affirm that I am licensed under the provisions ol'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 ofthe following two declarations:
I have and will maintain a certifiwatC Of Consent to self-insure for Worker's
Compensation,as provided for by Section 3700 ofthe Labor Code,for the
peribrinance ofthe work for which this permit is issued. Sq.Ft Floor Area: Valuation:$15000
I have and will maintain Worker's Compensation Insurance,as provided for by
Section 3700 ofthe Labor Code,for the performance ofthe work for which this AM Number:3622 004 00 Occupancy Type
permit is issued.
APPLICANT CF,R"1'IFIC:�'f10N
I ccrtify 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 180 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 DAYS FROM LAST CALLED INSPECTION
indemnify and keep harmless the City Of'Cupertino al-ainst liabilities,judgments,
costs,and expenses which may accrue against said City in consequence ofthe
granting Of this permit. Additionally,the applicant Understands and will comply Issued by: Date:
With all non-point source regulations per the Cupertino Municipal Code,Section
9 18.
12E-ROOFS:
Suinatore Date All roof*s shall be inspected prior to any roofing material being installed. 11'a mol u
installed without first obtaining in inspection.I agree to remove all new materrik In:
inspection.
❑ OWNER-BUILDER DECLARATION
Signature ol'Applicant. Date:
I hereby affirm that I amexempt from the Contractor's License Law for one of
the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BEITE'R
1,its owner ofthe 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,
13LISilICSS&Professions Code)
I.as owner ofthe property,am CXCILISiVCIV contracting with licensed contractors to HAZARDOUS NIATERIALS 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. 1 will
I hereby affirm under penalty of perjury one ofthe following three
maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
declarations: Ilealth&Safety Code,Section 25532(a)should I store or handle hazardous
l have and will maintain a Certificate ofConscrit to self-insure]-or Worker's material. Additionally,should I use equipment or devices which emit haZORIHIIS
Compensation,its provided for by Section 3700 ofthe Labor Code,for the air contaminants as defined by the Bay Arca Air Quality Nhinagenient District I
perl'ormance ofthe work for which this permit is iSSLIC(l. will maintain compliance with the Cupertino Municipal Code,Chapter 9 12 and
I have and will maintain Worker's Compensation Insurance,as provided flor by the I lealth&Safety Code,Sections 25505,25533,and 25534.
Section 3700 ofthe Labor Code,For the perlbrinance ofthe work l'or which this Owner orauthorized agent- Date:—
permit is issued.
I certil'y that in the performance of the work for which this permit is iSSLICd,I shall
not employ any person in any manner so as to become subject to the Worker's
Compensation laws of California. 1f,
after making this certificate of exemption,i CONSTRUCTION LEN'DING,AGENC)
become subject to the Worker's Compensation provisions ol'the Labor Code,I 111LISt I hereby affirm that there is a construction lending agency Im 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 infiorniation is
correct. I agree to comply with all city and COUllty 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
indernnily and keep harmless the City of'Cupertino against liabilities,jUdm
pents,
costs.and expenses which may accrue against said City in consequence of the
I understand my plans shall be Used as public record.,,'.
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 19.
Signature Date