B-2017-1050 CITY OF CUPERTINO BUILDING PERMIT '
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2017-1050
21050 RAINBOW DR CUPERTINO,CA 95014-5210(366 26 024) J S MILLER
CONSTRUCTION INC
CUPERTINO,CA
95015-0292
OWNER'S NAME: DATE ISSUED:09/05/2017
OWNER'S PHONE: • PHONE NO:(408)446-1407
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class B Lic.#899728 • .
Contractor J S MILLER CONSTRUCTION INC Date 07/31/2019 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(290 S.F.);DINING ROOM REMODEL(150 S.F.);
I hereby affirm under penalty of perjury one of the following two declarations: MASTER BEDROOM BATHROOM REMODEL(200 S.F.)
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.
• have and will maintain Worker's Compensation Insurance,as provided for by
1 Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued. Sq.Ft Floor Area: Valuation:$55000.00 •
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 APN Number: Occupancy Type:
and state laws relating to building construction,and hereby authorize 366 26 024
• 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,jtjdgments,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 p4the upertino!Municipal Code,Section 9.18. • 180 DAYS FROM LAST CALLED INSPECTION.
5,`;p.iure Date 9/5/2017 Issued by:Jasmine Archbold •
Date:09/05/2017
OWNER-BU DER DECLARATION
1 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.
sale(Sec.7044,Business&Professions Code)
2. I,as owner of the property,am exclusively contracting with licensed Signature of Applicant:
contractors to construct the project(Sec.7044,Business&Professions Code). Date:9/5/2017
I hereby affirm under penalty of perjury one of the following three declarations:
ALL ROOF COVERINGS TO BE CLASS"A"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
2. 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,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
3. . 1 certify that in the performance of the work for which this permit is issued,I Health&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 Qu• Management District I
Worker's Compensation laws of California. If,after making this certificate of will maintain compliance with the Cupertino Munic . ode,Chapter 9.12 and
exemption,I become subject to the Worker's Compensation provisions of the the Health&Safe
•
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,casts,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.
•
Signature Date 9/5/2017 Licensed -
Professional
•
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2017-1050
21050 RAINBOW DR CUPERTINO,CA 95014-5210(366 26 024) J S MILLER
CONSTRUCTION INC
CUPERTINO,CA
95015-0292
OWNER'S NAME: DATE ISSUED:09/05/2017
OWNER'S PHONE: PHONE NO:(408)446-1407
lk i._ _ et,' I_ G. BUILDING PERMIT INFO:
License Class GENERAL BUILDING CONTRACTOR Lic.#899728
Contractor J S MILLER CONSTRUCTION INC Date 07/31/2019 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(290 S.F.);DINING ROOM REMODEL(150 S.F.);
I hereby affirm under penalty of perjury one of the following two declarations: MASTER BEDROOM BATHROOM REMODEL(200 S.F.)
i. 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 REVISION#1: REPLACE SINGLE ENTRY DOOR AND SIDELITE
Via. frmance of the work for which this permit is issued. WITH(N)DOUBLE DOOR(72"x80")-ISSUED 9/28/2017
is issued. Sq.Ft Floor Area: Valuation:$55000.00
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 APN Number: Occupancy Type:
and state laws relating to building construction,and hereby authorize 366 26 024
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 regulation per the
9/28/2017 Issued by:ABBY AYENDE
Date:09/05/2017
OWNER-BUILDEI 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'roofmg material being installed.Ifa roof is
1. 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.
sale(Sec.7044,Business&,Professions Code)
2. I,as owner of the property,am exclusively contracting with licensed Signature of Applicant:
contractors:to construct the project(Sec.7044,Business&Professions Code). Date:9/28/2017
I hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"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
2. 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,for the performance of the work for which this California Health&Safety Code,Sections 25505,25533,and 25534. I will
maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
perniit is issued. Health&Safety Code,Section 25532(a)should I store or handle hazardous
3. I certify that in the pe formance of the work for which this permit is issued,I 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
APPLICANT CERTIFICATION Date:9/28/2017
I certify that I have readhthis 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 kc`onstruction lending agency for the performance
relating to building iconstructionf Iandihereby 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,:andezpensesIwhich 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'hon-pointsource regulations per the Cupertino Municipal ARCHITECT'S DECLARATION
Code,Section 9.181 ' I understand my plans shall be used as public'.records.
Signature Date 9/28/2017 Licensed .
Professional