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B-2017-1250CITY OF CUPERTINO BUILDING PERMIT .BUILDING ADDRESS: CONTRACTOR: PERMIT NO: B-2017-1250 840 ROSE BLOSSOM DR CUPERTINO, CA 95014-4214 (359 04 019) OWNER/BUILDER OWNER'S NAME:'. HOA LIAN DATE ISSUED: 08/02/2017 OWNER'S PHONE: 408-838-6808 PHONE NO: LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: License Class Lic. # Contractor OWNER/BUILDER Date X BLDG _ ELECT —PLUMB COMMERCIAL MECH X RESIDENTIAL 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. JOB DESCRIPTION: KITCHEN REMODEL (125 SF); REMODELED DINING ROOM & I hereby affirm under penalty of perjury one of the following two declarations: LIVING ROOM (550 SF) m. 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. z. 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 Sq. Ft Floor Area: Valuation: $45000.00 permit is issued. APPLICANT CERTIFICATION I certify that I have read this application sand 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 359 04 019 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 WORK IS NOT STARTED may accrue against said City in consequence of the granting of this permit. WITHIN 180 DAYS OF PERMIT ISSUANCE OR Additionally, the applicant understands; and will comply with all non -point source regulations per the Cupertino Municipal' Code, Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION. Signature Date 8/2/2017 Issued by: Kim Dunbar Date: 08/02/2017 OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for one of the RE -ROOFS: following two reasons: All roofs shall be inspected prior to any roofing material being installed. If a roof is r. I, as owner of the property, or my employees with wages as their sole installed without first obtaining an inspection, T agree to remove all new materials for compensation, will 'do the work; and the structure is not intended or offered for inspection. sale (Sec.7044, Business & Professions Code) I, as owner ofthe property, am exclusively contracting with licensed Signature ofApplicant: contractors to constrdet the project (Sec.7044, Business & Professions Code). prZyaffirm Date: 8/2/2017 I under penalty of perjury lone of the following three declarations: Ai,i •ROOF COVERINGS TO BE CLASS "All OR BETTER 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 performance of the work for which this permit is issued. HAZARDOUS MATERIALS DISCLOSURE z. I 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, forthe performance of the work for which this California Health & Safety Code, Sections 25505, 25533,, and 25534. I will permit is issued.,' maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the 3. I certify that in the performance of the work for which this permit is issued, I ealth & Safety Code, Section 25532(a) should I store or handle hazardous shall not employ, any person in any manner so as to become subject to the material. Additionally, should I use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management District I Worker's Compensation laws of California. If, after making this certificate of will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and exemption, I become subject to the Worker's Compensation provisions of the the Health & Safety Code Sect! s 25505, 25533; and 25534. Labor Code, I must' forthwith comply with such provisions or this permit shall be deemed revoked! Owner or authorized age APPLICANT CERTIFICATION Date: 8/2/2017 I certify that I have read thisappllcationland state that the above information is CONSTRUCTION LENDING AGENCY correct. I agree to comply .M all city and county ordinances and state laws I hereby affirm that there is a construction lending agency for the performance relating to building construction; and hereby authorize representatives of this city of work's for which this permit is issued (Sec. 3097, Civ C.) 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 exp"enses whichi 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 -point source regulations per the Cupertino Municipal ARCHITECT'S DECLARATION non Code, Section 9.1 1 understand my plans shall be used as public records. Licensed Signatu Date 912/2017 Professional CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2017-1250 840 ROSE BLOSSOM DR CUPERTINO,CA 95014-4214(359 04 019) OWNER/BUILDER OWNER'S NAME: CAMPBELL JOAN CAROL TRUSTEE DATE ISSUED:08/02/2017 OWNER'S PHONE:949-981-3784 PHONE NO: LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: • License Class Lie.# • Contractor OWNER/BUILDER Date X BLDG _ELECT _PLUMB MECH X RESIDENTIAL_COMMERCIAL 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. JOB DESCRIPTION: KITCHEN REMODEL(125 SF);REMODELED DINING ROOM& I hereby affirm under penalty of perjury one of the following two declarations: LIVING ROOM(550 SF) 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 REV#1: ADD STEEL BEAM WITH FOOTINGS TO GREAT ROOM TO performance of the work for which this permit is issued. SUPPORT THE EXISTING HIP ROOF-ISSUED 11-22-2007 2. 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:$45000.00 ' ;,APPLICANT CERTIFICATION . • I certify that I have read this application and state that the above information is correct.l:agree'to comply with all city and county ordinances APN Number: Occupancy Type: and state laws relating to building construction,and hereby authorize 359 04 019 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,'jtidgments,costs,and expenses which PERMIT EXPIRES.IF WORK IS NOT'STARTED may accrue against;said City in consequence of the granting of this permit. WITHIN 180 DAYS OF PERMIT ISSUANCE OR Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION. Signature. Date 11-22-2017 Issued by:Kim Dunbar Date:08/02/2017 I _! OWNER-BUILDER DECLARATION + i; • I hereby affirm that I am exempt from the Contractor's License Law for one of the RE-ROOFS: '' following two reasons: All roofs shall be inspected prior to any roofing material being installed.If a roof is i. I,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 inspection. e I / sale(Sec.7044,Business&Professions Code) N,L, (, z.J ll,as owner of the property,am exclusively contracting with licensed Signature of Applicant: tt1 fff `f contractors to construct the project(Sec.7044,Business&Professions Code). Date:11-22-2017 I hereby affirm tinder penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER 1. ' iI have and will maintain aCertificate of Consent to self-insure for Worker's - iCompehsation,as provided for by Section 3700 of the Labor Code,for the ,performance of the work foriwhich this permit is issued. HAZARDOUS MATERIALS DISCLOSURE 2. I have'andwill 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,Sections 25505,25533,and 25534. I will ,permit is issued. \ maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the a. I certify.that in the performance of the work for which this permit is issued,' Health&Safety Code,Section 25532(a)should I store or handle hazardous material. Additionally,should I use equipment or devices which emit hazardous shall not employ any'person in any manner so as to become subject to the air contaminants as defined by the Bay Area Air Quality Management District I Worker's Compensation laws of California. If,after making this certificate of will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and exemption;I become:subject to the Worker's Compensation provisions of the the Health&Safety Code,S tions 25 05,25533,and 25534. Labor Code,I must forthwith comply with such provisions or this permit shall be deemedlrevoked, Owner or authorized agent: APPLICANT CERTIFICATION Date:11-22-2017 I certify that I have read this application and state that the above information is CONSTRUCTION LENDING AGENCY correct.I agree to comply with all city and county ordinances and state laws I hereby affirm that there is a construction lending agency for the performance relating to building construction,and.hereby authorize representatives of this city of work's for which this permit is issued(Sec.3097„Civ C.) 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 DECLARATION Code,Section 9.18. � I understand my plans shall be used as public records. • SignaturLicensed e Date 11-22-2017 Professional - - I • • 1 .