B-2018-0833 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMITNO:B-2018-0833
10237 ADRIANAAVE CUPERTINO,CA 95014-1125(32620053) OWNER/BUILDER
OWNER'S NAME: DATE ISSUED:05/15/2018
OWNER'S PHONE: PHONE NO:
LICENSED CONTRAC'TOR'S DECLARATION BUILDING PERMIT INFO:
License Class Lia#
Contractor OWNER/BUILDER Date XBLDG 2C ELECT_PLUMB
I herebyaffirm that I am licensed under the _MECH X RESIDENTIAL_COMMERCIAL
provisions of Chapter 9(commencing
with Section 7000)cuf Division 3 of the Business&Professions Code and that my
license is in full force and effect. JOB DESCRIPTION:
TEMP POWER POLE(200 AMP)
1 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 Labor Code,for the
performance of the work for which this permit is issued.
2. 1 have and will maintain Worker's Compensation Insurance,as provided for by
Section 3700 of the Labor Code,for dee performance of the work for which this
permit is issued. Sq.Rt Fluor Aron: Valuation:81000.00
APPLICANT CERTIFICATION
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 AI'N Number. Occupancy'lype:
and state laws relating to building construction,and hereby authorize 326 20 053
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 WORT{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 05-15-2018 Issued by:Kim Dunbar
Date:05/15/2018
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 roof..material being installed If.roof is
er
1. I,as ownofthe 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
owner
of
Business&Professions Code)
/�,as ownceot the property,a exclusively contracting with licensed Si.nahue of Applicant
ontmctors to construct the project(Sm.7044,Business&Professions Code). Date:05-15-2018
1 hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO 13E CLASS"A"OR BET'rER
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
2. I have and will maintain Worker's Compensation insurance,as provided for by I have and the hazardous materials requirements under Chapter 6.95 of the
Section 3700 of the Labor Code,for alae performance of the won k for which this California Health&Safety Code,Sections 25505,25533,and 25534.1 will
permit is iss.ed. maintain compliance with the Cupertino Municipal Cade,Chapter 9.12 and the
a. I certify that in die performance of the work for which this permit is issued,I Health&Safety Code,Section 25532(x)should I store or handle hazardous
shall not employ any person in auy manner so as m become subject to the material.Additionally,should 1 use equipment or devices which emit hazardous
air contaminants as defined by the He,,Area Air Quality Management District l
Worker's Compensation laws o£Californis.If,a0cr makin.ihiscertifcate of will maintain compliance with the Copmtino Municipal Code,Chapter 9.12 and
exemption,I become subject to the Worker's Compensation provisions of the the I{ealth&Safety Code,Sections 2551 25533,and 25534.
Labor Code,I must forthwith comply with s-11 provisions or this permit shall
be deemed revoked Owner or authorized agent:_
APPLICANT CERTIFICATION Date:05-15-2018
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,...is,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. 1 understand my plans shall be used as public records.
Licensed
Signature Data 05-15-2018 professional