B-2016-3108G
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS:
CONTRACTOR:
PERMIT NO,
-2016-3108
10397 AMISTAD CT CUPERTINO, CA 95014-2606 (342 45 010)
FUTURE VISION
REMODELING INC
VAN NUYS, CA 91406
OWNER'S NAME: LU XIN
DATE ISSUED:
11/14/2016
OWNER'S PHONE: 408-799-1017
PHONE NO: (80))
485-4919
LICENSED D
ONTR A TOR' DECLARATION ATION
BUILDING PERMIT INFO:
License Class a Lic. #991840
Contractor EUTURE VISION REMODELING INC Date 04/30/2018
X BLDG _ELECT -PLUMB
I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing
_MECH X RESIDENTIAL —CORCIAL
with Section 7000) of Division 3 of the Business & Professions Code and that my
license is in full force and effect.
JOB DESCRIPTION:
2ND FLOOR BATHROOM REMODEL
E.M.P. -GUEST BATHROOM
I hereby affirm under penalty of perjury one of the following two declarations:
(40 SF) MASTER BATHROOM (135
SF) - TOTAL (175 SF)
1. 1 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.
Sq. Ft Floor Area:
Valuation: $1200.00
APPLICANT CERTIFICATION
certify that I have read this application and state that the above
APN Number:.
Occupancy
-
e:
information is correct. I agree to comply with all city and county ordinances
and state laws relating to building construction, and hereby authorize
342 45 010
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
PERMIT EXPIRES IF
ORK IS NOT STARTED
may accrue against said City in consequence of the granting of this permit.
Additionally, the applicant understands and will comply with all non-point
WITHIN 180 DAYS OF PERMIT
ISSUANCE OR
source regulations per the,Cupertino Municipal Code, Section 9.18.
180 DAYS FROM LAST
CALLED INSPECTION.
I
"Signature Date 11/14/2016
Issued by: Kim Dunbar
Date: 11/14/2016
OWNER-BUILDER DEL RATION
I hereby
affirm that I am exempt from the Contractor's License Law for one of the
following two reasons:
All roofs shall be inspected prior to any ropfng
material being installed. If a roof is
t. 1, as owner of the property, or my employees with wages as their sole
installed without first obtaining an inspection,
I agree to remove all new materials for
compensation, will do the work, and the structure is not intended or offered for
inspec
tion.
sale (Sec.7044, Business & Professions Code)
z. 1, as owner of the property, am exclusively contracting with licensed
Signature of Applicant:
contractors to construct the project (Sec.7044, Business & Professions Code).
Date: 11/14/2016
I hereby affirm under penalty of perjury one of the following three declarations:
ALL ROOF COVERINGS TO
BE CLASS "A" OR BETTER
1. 1 have and will maintain a Certificate ofConsent 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.
HAZARDOUS MATERIALS
DISCLOSURE
2. 1 have and will maintain Worker's Compensation Insurance, as provided for by
I have read the hazardous materials requirements
under Chapter 6.95 of the
Section 3700 of the Labor Code, for the performance of the work for which this
California Health & Safety Code, Sec
ions 25505, 25533, and 25534. 1 will
permit is issued.
maintain compliance with the Cupertino
Municipal Code, Chapter 9.12 and the
s. 1 certify that in the performance of the work for which this permit is issued, I
Health & Safety Code, Section 25532(a)
material, Additionally, should I use equi
should,1- store or- handle hazardous
mentor devices which emit hazardous
shall not em to
p y any person in any manner so as to become subject to the
air contaminants as defined by the Bayea
Air Quality Management District I
Worker's Compensation laws of California. If, after making this certificate of
will maintain compliance with the Cupe�tino
Municipal Code, Chapter 9.12 and
exemption, I become subject to the Worker's Compensation provisions of the
the Health & Safety Code, Sectl
a 25505, 25533, and 25534.
Labor Code, I must forthwith comply with such provisions or this permit shall�
��
be deemed revoked. C,_-Owner
or authorized agent:
APPLICANT CERTIFICATION
Date: 11/14/2016
1 certify that I have read this application and state that the above information is
CONSTRUCTION IJENDING
AGENCY
correct. I agree to comply with all city and county ordinances and state laws
I hereby affirm that there is a construction
of work's for which this permit is issued
lending agency for the performance
l(Sec. 3097, Civ C.)
relating to building construction, and hereby authorize representatives of this city
to enter upon the above mentioned property for inspection purposes. (We) agree
Lender's Name
to save indemnify and keep harmless the City of Cupertino against liabilities,
judgments, costs, and expenses which may accrue against said City in
Lender's Address
consequence of the granting of this permit. Additionally, the applicant understands
and will comply with all non-point source regulations per the Cupertino Municipal
ARCHITECT'S DECLLA—RATI
E
Code, Section 9.18.
1 understand my plans shall be used as
public records.
Signature Date 11/14/2016
Licensed
Professional
.71 CONSTRUCTION PERMiT APPLICATION
COMMUNITY DEVELOP10ENT DEPARTMiENT • BUILDING DIVISION
10300 T OrRRE AVENUE • CUPERTINO, CA 95014-3255
r (408) 777-3228 • c?X (408) 777-3333 • buildinala cuaertino.org
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