B-2016-2651
I have and will maintain Worker's Compensation Insurance, as provided for by
KITCHEN; (N) FURNACE
SAME LOCATION (200
/A/C IN ATTIC; (I) PANEL UPGRADE IN
S); RE -ROOF (E); TEAR -OFF; CDX;
Section 3700 of the Labor Code, for the performance of the work for which this
COMP SHINGLES (20 SQ);
(I) STUCCO ON EXISTING PORTION OF
permit is issued.
RESIDENCE (1240 SF).
APPLICANT CERTIFICATION
Sq. Ft Floor Area: 672
Vali
ation: $150000.00
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
APN Number:
Occupancy
type:
and state laws relating to building construction, and hereby authorize
representatives of this city to enter upon the above mentioned property for
366 11030
De+&d
Submittal (R -3),R-3 (Custom)
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 the granting this permit.
PERMIT EXP
S IF WORK IS NOT STARTED
Additionally, the applicant understands and willl comply with allll non -point
source regulations per the Cupertino Municipal Code, Section 9.18.
WITHIN 180 DA
S OF PERMIT ISSUANCE OR
180 DAYS FROM
LAST CALLED INSPECTION.
Signature Date 1/13/2017
Issued by: Kim Dunbar
OWNE-
Date: 01/13/2017
I hereby affirm that I am exempt from the Contractor's License Law for one of the
following two reasons:
PXROOFS:
1. I, as owner of the property, or my employees with wages as their sole
All roofs shall be inspected pi
'or to any roofing material being installed. If a roof is
compensation, will do the work, and the structure is not intended or offered for
installed without first obtaining
an inspection, I agree to remove all new materials for
sale (Sec.7044, Business & Professions Code)
inspection.
z. I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Scc.7044, Business & Professions Code).
Signature of Applicant:
I hereby affirm under penalty of perjury one of the following three declarations:
Date: 1/13/2017
1. 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
ALL ROOF COVERINGS
TO BE CLASS "A" OR BETTER
performance of the work for which this permit is issued.
2. I have and will maintain Worker's Compensation Insurance, as provided for by
HAZARDOUS
MATER AL L RE
Section 3700 of the Labor Cade, for the performance of the work for which this
I have read the hazardous
materials requirements under Chapter 6.95 of the
permit is issued.
California Health & Safei
y Code, Sections 25505, 25533, and 25534. I will
s. I certify that in the performance of the work for which this permit is issued, I
maintain compliance with ti
e Cupertino' Municipal Code, Chapter 9.12 and the
shall not employ any person in any manner so as to become subject to the
Health & Safety Code, Se
tion 25532(a) should I store or handle hazardous
Worker's Compensation laws of California. If, after making this certificate of
material. Additionally, shoo
d I use equipment or devices which emit hazardous
exemption, I become subject to the Worker's Compensation provisions of the
air contaminants as defined
by the Bay Area Air Quality Management District I
Labor Code, I must forthwith comply with such provisions or this permit shall
will maintain compliance with
the Health & Safely
the Cupertino Municipal Code, Chapter 9.12 and
Code, Sections 25505, 25533, and 25534.
be deemed revoked,
APPLICANT CERTIFICATION �
j
Owner or authorized agent:
certify that I have read this application and state that the above information is
Date: 1/13/2017
correct. I agree to comply with all city and county ordinances and state laws
CONS
ITTCVON LENI�� AGENCY
relating to building construction, and hereby authorize representatives of this city
I hereby affirm that there is
3 construction lending agency for the performance
to enter upon the above mentioned property for inspection purposes. (We) agree
of work's for which this perr
it is issued (Sec. 3097, Civ C.)
to save indemnify and keep harmless the City of Cupertino against liabilities,
Lender's Name
judgments, costs, and expenses which may accrue against, said City in
consequence of the granting of this permit. Additionally, the applicant understands
Lender's Address
and will comply with all non -point source regulations per the Cupertino Municipal
Code, Section 9.18.
ARC'HTTFCT'S
DECLARATION
I understand my plans shal
be used as public records.
Signature Date 1/13/2017
Licensed
Professional