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B-2017-0155 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2017-0155 11801 DOROTHY ANNE WAY UNIT 6 CUPERTINO,CA(366 09 043) HOMEOWNER BUILDER OWNER'S NAME: DATE ISSUED: 10/03/2017 OWNER'S PHONE: PHONE NO: LICENSED CONTRACTOR'S DECLARATION • BUILDING PERMIT INFO: • License Class Lic.# . Contractor HOMEOWNER 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: TO CLEAR CODE ENFORCEMENT: UNIT 6(GARDENER'S I hereby affirm under penalty of perjury one of the following two declarations: COTTAGE)-DEMOLISH ADDITION,ROOF AND PORCH 1. I have andiwillimaintain a certificate of consent to self-insure for Worker's STRUCTURES(731 S.F.);RESTORE HISTORIC HIP ROOF Compensation,las provided for by Section 3700 of the Labor Code,for the STRUCTURE AT MASTER BEDROOM(204 S.F.);(N)WINDOW IN performance of the work for which this permit is issued. LAUNDRY ROOM;(N)SIDING(774 S.F.);RESTORE COVERED 2. I have andiwill;maintain Worker's Compensation Insurance,as provided for by PORCH AND STAIRS. Section 3700 of the Labor Code,for the performance of the work for which this permit is isued. Sq.Ft Floor Area: Valuation:$35000.00 ' i APPLICANT CERTIFICATION I certify that I have readlthis 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 09 043 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 againstsaid 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 regulationsper the Cupertino Municipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION. Signature Date 10/3/2017 Issued by:Abby Ayende Date: 10/03/2017 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: 1 All roofs shall be inspected prior to any roofing material being installed.If a 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. ale(Sec.7044,Business&Professions Code) as owner of the property,am exclusively contracting with licensed Signature of Applicant: contractors to construct the project(Sec.7044,-Business&Professions Code). Date:10/3/2017 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 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.' I certify that in the performance of the work for which this permit is issued,I Health&Safety Code,Section 25532(a)should 1 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,Sections 25505,25533,and 25534. Labor Code,I must forthwith comply with such provisions or this permit shall I be'deemed revoked. �� . �* ner t or authorized agent: _ APPLICANT CERTIFICATION Date:10/3/2017 ------------,` I certify that I have read this application and state that the above information is CONSTRUCTION LENDING AGENCY., correbf.1 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 enterupon 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. 4,io , S.i turre ; . '' - -Date 10/3/2017 Professional 40 J , CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2017-0155 11801 DOROTHY ANNE WAY UNIT 6 CUPERTINO,CA(366 09 043) OWNER'S NAME: DATE ISSUED: 10/03/2017 OWNER'S PHONE: PHONE NO: LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: License Class Lic.# Contractor Date X BLDG X ELECT —PLUMB I hereby affirm that I am licensed under the provisions of Chapter 9(commencing MECH X RESIDENTIAL_COMMERCIAL with Section 7000)of Division 3 of the Business&Professions Code and that my license is in full force and effect. JOB DESCRIPTION: REV#1-INSTALL NEW PANEL 000 AMP);INSTALL NEW OUTLETS I hereby affirm under penalty of perjury one of the following two declarations: (24),RECESSED LIGHT(2 1) t I have and will maintain a certificate of consent to self-insure for Worker's TO CLEAR CODE ENFORCEMENT: UNIT 6(GARDENER'S Compensation,as provided for by Section 3700 of the Labor Code,for the COTTAGE)-DEMOLISH ADDITION,ROOF AND PORCH performance of the work for which this permit is issued. STRUCTURES(731 S.F.);RESTORE HISTORIC HIP ROOF 2. I have and will maintain Worker's Compensation Insurance,as provided for by STRUCTURE AT MASTER BEDROOM(204 S.F.);(N)WINDOW IN Section 3700 of the Labor Code,for the performance of the work for which this LAUNDRY ROOM;(N)SIDING(774 S.F.);RESTORE COVERED permit is issued. PORCH AND STAIRS. APPLICANT CERTIFICATION REV#I-INSTALL NEW PANEL(100 AMP);INSTALL NEW OUTLETS I certify that I have read this application and state that the above (24),RECESSED LIGHT(21)-ISSUED 9/13/18 information is correct.I agree to comply with all city and county ordinances and state laws relating to building construction,and hereby authorize Sq.Ft Floor Area: Valuation:$35000.00 representatives of this city to enter upon the above mentioned property for inspection purposes. (We)agree to save indemnify and keep harmless the APN Number: Occupancy Type: City of Cupertino against liabilities,judgments,costs,and expenses which 366 09 043 may accrue against said City in consequence of the granting of this permit. Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. PERMIT EXPIRES IF WORK IS NOT STARTED Signature Date 09/13/18 WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTION. OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for one of the Issued by:Abby Avende following two reasons: Date: 10/03/2017 t. 1,as owner of the property,or my employees with wages as their sole compensation,will do the work,and the structure is not intended or offered for RE-ROOFS: sale(Sec.7044,Business&Professions Code) All roofs shall be inspected prior to any roofing material being installed.If a roof is 2. I,as owner of the property,am exclusively contracting with licensed installed without first obtaining an inspection,I agree to remove all new materials for contractors to construct the project(Sec.7044,Business&Professions Code). inspection. I hereby affirm under penalty of perjury one of the following three declarations: t. I have and will maintain a Certificate of Consent to self-insure for Worker's Signature of Applicant: Compensation,as provided for by Section 3700 of the Labor Code,for the Date:09/13/18 performance of the work for which this permit is issued. z. I have and will maintain Worker's Compensation Insurance,as provided for by ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. HAZARDOUS MATERIALS DISCLOSURE 3. I certify that in the performance of the work for which this permit is issued,I I have read the hazardous materials requirements under Chapter 6.95 of the shall not employ any person in any manner so as to become subject to the California Health&Safety Code,Sections 25505,25533,and 25534. I will Worker's Compensation laws of California. If,after making this certificate of maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the exemption,I become subject to the Worker's Compensation provisions of the Health&Safety Code,Section 25532(a)should I store or handle hazardous Labor Code,I must forthwith comply with such provisions or this permit shall material. Additionally,should I use equipment or devices which emit hazardous be deemed revoked. air contaminants as defined by the Bay Area Air Quality Management District I will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and APPLICANT CERTIFICATION the Health&Safety Code,Sections 25505,25533,and 25534. 1 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 and state laws relating to building construction,and hereby authorize representatives of this city Owner or authorized agent: to enter upon the above mentioned property for inspection purposes. (We)agree Date:09/13/18 to save indemnify and keep harmless the City of Cupertino against liabilities, CONSTRUCTION LENDING AGENCY judgments,costs,and expenses which may accrue against said City in I hereby affirm that there is a construction lending agency for the performance consequence of the granting of this permit. Additionally,the applicant understands of work's for which this permit is issued(Sec.3097,Civ C.) and will comply with all non-point source regulations per the Cupertino Municipal Lender's Name Code,Section 9.18. Lender's Address Signature Date 09/13/18 ARCHITECT'S DECLARATION I understand my plans shall be used as public records.