B-2018-0817 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2018-0817
10171 PHAR LAP DR CUPERTINO,CA 95014-1113(326 39 055) OWNER/BUILDER
OWNER'S NAME: DATE ISSUED:05/10/2018
OWNER'S PHONE: PHONE NO:
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class Lic.#
Contractor OWNERIBUILDER Date X BLDG ELECT—PLUMB
I hereby affirm that 1 nm licensed ander the provisions ol'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:
TEAR-OFF;RE-ROOF;INSTALL OSB;COMP SHINGLE(36 SQ)
I hereby affirm under penalty of perjury one of the following two declarations:
r. 1 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.
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 dais
permit is issued. Sy.Ft Fluor Area: Valuation:$11500.00
APPLICANT CF.RTiFJ(:ATION
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 slate laws relating to building construction,and hereby authorize 32639 055
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 9.1 B. 180 DAYS FROM LAST CALLED INSPECTION.
Signature Data 5-10-2018 Issued by:Kim Dunbar
Data 05/10/2018
QWNER-BUILDER DECLARATION
v-- I hereby affirm that I am exempt from the Contractor's License Law for one of the RE-ROOFS,
1,as owner of the property,am exclusively contracting with licensed Signsture ofApplicaut:
contractors to construct the project(Sce.7044,Business&Professions Code), Date:5-10-2018
1 hereby affirm undev penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER1. 1 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 rend the hazardous materials requirements under Chapter 6.95 of the
Section 3700 oflhe 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. m aintaa compliance with the Cupertino Municipal Code,Chapter 9.12 and the
,
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s Compensation laws of California.If,after making this certificate of will
maintain compliance with the Cupertino MI kni nl Code, Irapter 9.12 and
exemption,1 become subject to the Worker's Compensation provisions of the the health&Safety Code,Sectiy 25505,'5533,. 25534.
Labor Code,I must forthwith comply with such provisions or this permit shall /!/
be doomed revoked. 'Owner or authorized agent:
APPLICANT CER'I'I FICATION Date:5-10-2018
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 r ulations per the Cupertino Municipal ARCHITECT'S DECLARATION
Code,Section 9.18. � I understand my plans shall be used as public records.
Signature Date 5-10-2018 Licensed
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