B-2018-0394 CITY OF CUPERTINO BUILDING PERMIT
BU ILDINGADDRESS: CONTRACTOR; PERMIT NO;B-2018-0394
22090 HIBISCUS DR CUPERTINO,CA 95014-0109(326 02 030) SAM'S REMODELING
&CONSTRUCTION
REDWOOD CITY,CA
94063
OWNER'SNAME: DATE ISSUED;03/06/2018
OWNER'S PHONE: PHONE NO:(
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO'
License Class B Lic.#883883
Contractor SAM'S REMODELING&CONSTRUCTION Date 09/30/2018 X BLDG X ELECT_PLUMB
1 hereby affirm that 1 am licensed under the provisions at'Chapter 9(commencing MECH X RESIDENTIAL_COMMERCIAL
with Section 7000)of Division 3 of the Business&Professions Code and that any
license is in full farce and effect. JOB DESCRIPTION:
MASTER BEDROOM BATHROOM REMODEL(168 S.P.)
I hereby aflirm under penalty of perjm•y one of the following I've declarations: REV#I UPGRADE PANEL(200 AMPS)-ISSUED 05/14/2018
3700 of the Labor Code,For the performance of the work for which this
permit is issued. Sq.Ft Floor Area: Vnlnation:$25000.00
APPLICANT CERTIFICATION
I certify that I have read this application and slate 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 326 02 030
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 again t-sa�i\Id City in consequence of the granting of this permit. WITHIN 180 DAYS OF PERMIT ISSUANCE OR
Additionally,the a pIIC20 understands and will comply with all non-point
source regulati Municipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
Signature Date 05/14/2018 Issued by:Abby Ayende
Date;03/06/2018
OWNER-BUILDER DECLA ATION
1 hereby affirm that 1 am exempt from the Contractor's License Lav for one of the RE-ROOFS:
following two reasons: All roofs shall be inspected prior to any roofing more,let being installed.If..of is
t. I,as owner of the property,or my employe v with wages as then sole installed without first obtaining on 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(See.7044,Business&Professions Code)
z. I,as owner of the property,am exclusively contracting with licensed Signature of Applicant:
contractors to construct the project(See.7044,Business&Professions Code). Date:05/14/2018
1 hereby aflirm mrder penalty of f erjury one of the following three declarations; ALL ROOF COVERINGS'1'0 BE CLASS"A"OR BETTER
r. 1 have and will maintain a Certificate of Conscet to self-Insure for Worker's
Compensation,as provided for by Section 3700 o£the Labor Code,for the
performance ofthe work for which this permit is issued. HAZARDOUS MATERIALS DISCLOSURE
z. 1 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 far which this permit is issued,l Health&Safety Code,Section 25532(a�hhmdd I store or handle ImzaMous
shall..(employ an Person In an material.Additionally,should I use egrf,enTb��devlces wilfch emit Iraxardons
1 y• y p y manner so as to become subject to the at r contamfnnnts as defined by the Bay ren All.Qd try Management District I
Worker's Compensation laws of California.If,alter making this certificate of twill maintain emnplimme with the Cu er'((ro Man ci al-Gade,Chapter 9.12 and
exemption,I become subject to the Worker's Compensation provisions of the the Health&Safety Code,S
Labor Code,I must fofhwith comply with such provisions or this peianit shall
be deemed revoked. Owner or authorized agent:
APPLICANT CERTIFICATION Date:05/14/2018
I certify that I have read this application and state that the above Information is CONSTR "ION LENDIN GF,NCY
correct.I agree to comply with all city and county ordinances and state laws I hereby affirm that there is a construction lending gency 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.)
toenter 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 ARCHCI'EC FS DECLARATION
Code,Section 9.18. 1 understand my plans shall be used as public records.
Signature Dale 05114/2018 Licensed
Professional