B-2017-1170 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2017-1170
10400 FARALLONE DR CUPERTINO,CA 95014-3105(369 29 013) O WNER/BUILDER
OWNER'SNAME: DA'T'E ISSUED:05/25/2018
OWNER'S PHONE: PHONE NO:
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class Lia#
Contractor OWNERIBUILDER Date X BLDG—ELECT PLUMB
I hereby aflirm that I mn licensed corder the provisions of Chapter 9(commencing —MECII X RESIDENTIAL—COMMERCIAL
with Section 7000)of Division 3 ofthe Business&Professions Code and that my
license is in full force and effect, JOB DESCRIPTION:
IST FLOOR BATHROOM,OFFICE AND BEDROOM ADDITION(486
I hereby affirm under penalty of perjury one of the following two declarations: &F.)
r. 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 Cede,for the
performance ofthe work for which this permit is issued,
I, I have and will maintain Worker's Compensation Insurance,as provided For by
Section 3700 ofthe Labor Code,for the performance ofthe work for which this
permit is issued. Sq.Ft Fluor Area:486 Valuation:,$100000.00
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 369 29 013 R-3(Custom)
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 5 25 18 Issued by:SEAN I-IATCI-I
Date:05/25/2018
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Low for one ofthe RE-ROOFS:
following two reasons: All roofs shall be inspected prior to any roofing material being installed.If n roof is
r. 1,as owner ofthe property,or my employees with wages as their sole insudled without first obtaining an inspection,1 agree to remove all new materials for
compensation,will do the work,and the structure is Dot intended or offered for inspection.
sale(Sec.7044,Business&Professions Code)
z. I,as owner ofthe property,am exclusively contracting with licensed Signature ofApplicaut:
contractors to construct the project(Sec.7044,Business&Professions Code), Date:5.25.18
1 hereby affirm under penalty of perjury one of the following three declamations: ALL ROOF COVEIi1NC5'1'O BE CLASS"A"012 BE'I"fEli
r. I have and will maintain a Certificate of Consent to self-insure for Worker's
Compensation,us provided for by Section 3700 of the Labor Code,for the
performance ofthc work For which this permit is issued. HAZARDOUS MATERIALS DISCLOSURE
z. I have and will maintain Worker's Compensation Intmomec,as provided for by I have read the hazardous materials requirements under Chapter 6.95 of the
Section 3700 ofthe Labor Code,for the performance ofthe Werk for which this California Health&Safety Cade,Sections 25505,25533,and 25534.1 will
permit is issued. maint in compliance with the Cupertino Municipal Code,Chapter 9.12 and the
III{�
shall not employ in an manner so as to become subject to the material.Additionally,should I use equipment or devices which emit hazardous
p y any person y man .I air confamin..ts.s defined by the Bay Are.At,Quality Management District I
Worker's Compensation laws of California.If,after making this certificate of will maintain compliance with the Cupertino Municipal Cade,Chapter 9.12 and
exemption,I become subject to the Worker's Compensation provisions o£the the Health&Sat'ety Cordon,25505,25533,and 25534.
Labor Code,I must forthwith comply with such provisions or this permit shall
be deemed rc,.IcdOwner or authorized agent
APPLICANT CERTIFICATION Date:5 25.18
1 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,S :18. I understand my plans shall be used as public records.
Licensed'
Signalura Date 5.25.18 Professional
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2017-1170
10400 FARALLONE DR CUPERTINO,CA 95014-3105(369 29 013) OWNER/BUILDER
OWNER'S NAME: DATE ISSUED:05/25/2018
OWNER'S PHONE: PHONE NO:
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class Lic.#
Contractor OWNER/BUILDER Date X BLDG —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:
1 ST FLOOR BATHROOM,OFFICE AND BEDROOM ADDITION(486
I hereby affirm under penalty of perjury one of the following two declarations: S.F.)
1. I have and will maintain a certificate of consent to self-insure for Worker's REV#1 -SWAP OUT LOCATIONS OF BATHROOM AND WALK-IN
Compensation,as provided for by Section 3700 of the Labor Code,for the CLOSET-ISSUED 9-6-2018
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
permit is issued. Sq.Ft Floor Area:486 Valuation:$100000.00
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 369 29 013 R-3(Custom)
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 9-6-2018 Issued by:SEAN HATCH
Date:05/25/2018
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: 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.
sale(Sec.7044,Business&Professions Code)
z. 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:9-6-2018
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
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,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 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&Safet_C ections 25505,25533,and 25534.
Labor Code,I must forthwith comply with such provisions or this permit shall
be deemed revoked. Owner or authorized agent: '
APPLICANT CERTIFICATION Date:9-6-2018
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,S . . I understand my plans shall be used as public records.
Licensed
Signature Date 9-6-2018 Professional