B-2018-0803 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2018-0803
10220 JOHNSON AVE CUPERTINO,CA 95014-3812(375 25 064) OWNER/BUILDER
OWNER'SNAME: DA'Z'E ISSUED:05/29/2018
OWNER'S PHONE: PHONE NO:
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class Uc,#
Contractor OWNEWBUILDER Date X BLDG_ELECT_PLUMB
I herebyfirm that I am licensed under the _MECH X RESIDENTIAL_COMMERCIAL
a provisions ol'Chnpter 9(commeming
with Section 7000)of Division 3 of the Business&Professions Code and that my
license is in full forte and effect JOB DESCRIPTION:
TO CLEAR CODE ENFORCEMENT CASE:DEMO UNPERMITTED
I hereby affirm under penalty of perjury one of the following two declarations: ATTACHED UNIT(300 S.F.)
1. I have and will maintain a certificate of emnsent to self-insure far 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.
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:$5000.00
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 slate laws relating to building construction,and hereby authorize 37525 064
.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 Data 05/29/2018 Issued by;Jasmine Archbold
Date:05/29/2018
OWNER-BIJILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of the RE-ROOFS:
following hvo reasons: All roofs shall be inspected In to any rooting material being installed.if a root'is
u 1,as owner of the property,army employee with wages as their set, nstalled without first obtaining an inspection,I agree to remove all new materials for
ompamettion,will do the work,and the structure aunt intended m offered for inspection.
sale(Sec.7044,Business&Professions Code)
I,as owner of the property,are exclusively contracting with licensed Siguehue ofApplicant:
contractors to construct the project jSce.7044,Business&Professions Code), Date:05/29/2018
1 hereby affirm under penalty ofpmjury one of the following three declarations: ALL ROOF COVEI2INGS'1'O 13E CLASS"A"OR BETTERr, 1 have and will maintain a Certificate of Consent to self-insure for Worker's
Compensation,as provided for by Section 3700 df the Labor Code,far the
erfrmance ofthe work for which this permit is issued HAZARDOUS MATERIALS DISCLOSURE
have and will maintain Worker's Compensation Insurance,as provided par by I have rend the hazardous nmteriels requirements under Chapter 6.95 of the
Section 3700 ofthc 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. I certify that in the performance of the work for which this permit is issued,l Health&Safety Cade,Section 25532(x)should I store or handle hazardous
shall not employ any person in any manner so as to become subject to the mntc rinl.Additiolly,should I use equipment at-devices which emit hazardous
onmmna
inants as defined by the Bay Area Air Qrmlity Management District I
Worker's Compensation laws ofCalif.mou If,after making this certificate of will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and
exemption,I became subject lathe Worker's Compensation provisions of the the Health&Sofety Code,Sections 25505 5533,and 25534.
Labar Cade,1 must forthwith comply with such provisions or this permit shall
be deemed revoked. - Owner or authorized agent:
APPLICANT CERTIFICATION Date;05/29/2018
1 certify that I have read this application and slate that the above information is CONSTRUCTION 1,
ENDING 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 ARCIIITECT'S DECf.ARATION
Code,Section 9.18. 1 understand my plans shall be usedas public records.
Licensed
Signature Date 05/29/2018 professional