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B-2017-2004 CITY OF CUPERTINO BUILDING PERMIT BUI LDING ADDRESS: CONTRACTOR: PERMIT NO:B-2017-2004 1180 ELMSFORD DR CUPERTINO,CA 95014-4950(362 09 007) VAKHARIYA PARESH AND SINGH ARCHANATRUSTEE 1180 ELMSFORD DR CUPERTINO,CA 95014-4950 OWNER'S NAME: DATE ISSUED:01/24/2018 OWNER'S PHONE: PHONE NO:None LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: License Class B Lic.# Contractor VAKHARIYA PARESH AND SINGH ARCHANATRUSTEE Date cX 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: ONE STORY ADDITION(686 SF);CONVERT BEDROOM INTO A I hereby affirm under penalty of perjury one of the following two declarations: FULL BATHROOM(108 SF);OTHER REMODEL(148 SF);REMOVE m. I have and will maintain a certificate of consent to self-insure for Worker's WALL BETWEEN KITCHEN/LIVING RM/ENTRY;COVERED PORCH Compensation,as provided for by Section 3700 of the Labor Cade,for the (40 SF). performance of the work for which this permit is issued. REV#I-ADD(N)SUB-PANEL IN GARAGE(80 AMPS)-ISSUED I have and will maintain Worker's Compensation Insurance,as provided for by 05/23/2018 Section 3700 of the Labor Code,for the per of the work for which this permit is issued Sq.Ft Flnor Area:686 Valuation:$127000.00 APPLICAN7'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: Occupaucy'1'ypm and state laws relating to building construction,and hereby authorize 362 09 007 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 Cade,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION. Signature �^ Date 05/23/2018 Issued by:Kim Dunbar Data:01/24/2018 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 materiel being installed.IC a roof is r. I,as owner ofthe property,or my employees with wages as their sole installed without first obtaining an inspection,I agree to reprove 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) x. I,as owner ofthe property,am exclusively contracting with licensed Signature ofApplieant: contractors to construct the project(See.7044,Business&Professions Code). Date:05/23/2018 1 hereby affirm under penally of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTERm. 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. 1 have and will maintain Worker's Compensation Insurance,as provided for by I have feud 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 s. I certify that in the performance of the work for which this permit is issued,I Health&Safety Cade,Section 25532(a)should I stare or handle hazardous shall not employ any person in any runner so as to become subject to the motm•lol.Additionally,should I use equipment or devices which emit hazardous air contaminants as deRned by the Bay Area Air Quality Management District 1 Worker's Compensation laws ofCaliforuie.If,after making this certificate of will nntntuln 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 Cade,Sections 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:05/23/2018 I certify that I have read this application and State that the above Information Is CONSTRUC'T'ION 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 ARCHT' ITECS DECLARA'IAON Code,Section 9.18. 1 understand my plans shall be used as public records.