B-2018-0940 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2018-0940
20560 RODRIGUES AVE CUPERTINO,CA 95014-2942(359 17 017) CURTIS D WAYNE
HAIKU,HI 96708
OWNER'S NAME: DATE ISSUED:05/31/2018
OWNER'S PHONE: PHONE NO:(
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class C20 Lie.#789207
Contractor CURTIS DWAYNE Date 12/31/2020 X BLDG ELECT—PLUMB
I hereby affirm that I am licensed under the provisions of Chapter 9(commencing X 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:
INSTALL(N)A/C UNIT-BACK
I hereby affirm under penalty of perjury one of the following two declarations:
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 Lathan 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 Fluor Area: Valuation:$5500.00
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 359 17 017
representatives of this city to enter upon the above mentioned property for
inspectlon 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 agalnst sold City in consequence of the granting of this permit. WITHIN 180 DAYS OF PERMIT ISSUANCE OR
Additionally,the appllcanl underst n and w111 comply with all non-point
source regulations perthe Gu in unicipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
Signature ate-05/31/2018 Issued by:Jasmine Archbold
Date:05/31/2018
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: A11 roofs shall be inspected prior to any roofing material being installed.I£a root'is
1. 1,as owner ofthe property,or my employee with wages as their sole nstalled without first obtaining an inspection,I agree to remove all new materials for
compensation,will do the work,and the an acture is not intended or offered for inspection.
sale(Sec,7044,Business&Professions Code)
z. I,as owner offhc property,am exclusively contracting with licensed Signature ofApplicanC
convectors to construct the project(Sec.7044,Business&Professions Code), Date:05/31/2018
1 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 die work for which this permit is issued. HAZARDOUS MATERIALS DISCLOSURE
a. 1 have and will maintain Worker's Compensation Insurance,as provided for by 1 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 25534.1 will
permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
s. 1 certify that in the perfonnau.e of the work far which this permit is issued,I Health&Safety Cade,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 1 use equipment or devices which emit hazardous
air contaminants as defined by the Bay Arca Air Quality Management District 1
Worker's Compensation laws of California.If,after making this certificate of will maintain compliance with the Cupertino Munieipa Cade,Chapter 9.12 and
exemption,I become subject to the Worker's Compensation provisions of the the Health&Safety Code,Sections 25505 33,and 25534.
Labor Code,I must forthwith comply with such provisions or this permit shall
be deemed revoked. Owner or authorized agen
APPLICANT CERTIFICATION Data:05/311 tl
I certify that I.have read this application and state that the above information is CONST RUCTIO DI
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,Clv 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 ARCH['PF.C'1"S DF,CLARATION
Code,Section 9.18. 1 understand my plans shall be used as public records.
Signature Data 05/31/2018 Licensed
Professional