D-2018-0043 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:D-2018-0043
10645 JOHN WAY CUPERTINO,CA 95014-4345(359 19 010) LASSITER
EXCAVATING INC
TRACY,CA 95376
OWNER'S NAME:FAM SUN TIEN AND RUSLI POLIMING DATE ISSUED:06/18/2018
OWNER'S PHONE: PHONE NO:(925)449-3112
LICENSED 'C BUILDING PERMIT INFO:
License Class A C21 Lin.#579261
Contractor LASSITER EXCAVATING INC Date 10/31/2019 —BLDG ELECT_PLUMB
1 herebyaffirm that I am licensed under the provisions of Chapter 9 —MECH$RESIDENTIAL_COMMERCIAL
P P (commencing
with Section 7000)of Division 3 of the Business&Professions Code and that my
license is in full force and effect. JOB DESCRIPTION:
DEMOLITION OF SWIMMING POOL(475 SF)-COMPACTION FOR
I hereby affirm under penalty of perjury one of the following two declarations: 90%-PROVIDE ENGINEER COMPACTION REPORT PRIOR TO
r. I have and will maintain o certificate of consent to self-insure for Workcr's FINAL
Compensation,as provided for by Section 3700 of the Labor Code,for the
szperformance of the work for which this permit is issued.
. 1 have and will notintain Worker's Compensation Insurance,as provided far by
Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued. Sq.Ft Floor Area: Valuation:$12800.00
APPIJCANT 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 stale laws relating to building construction,and hereby authorize 359 19 010
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 1$0 DAYS OF PERMIT ISSUANCE OR
Additionally,the applicant understands and will comply with all non-point
source regulations per fie Cupertino Municipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
Signature Data 06-18-2018 Issued by:Kim Dunbar
Date:06/18/2018
OWNER-BUILD�R DECLARATION
I hereby affirm that I am exempt Brom 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
I. 1,as owner orthe 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(Sae.7044,Business&Professions Cade)
z. 1,as owner of the property,am exclusively contracting with licensed Signature ofAppliceut
contractors to construct the project(Sec.7044,Business&Professions Code), Date:06-I5-2018
I hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO 13E CLASS"A"OR BETTER
I. 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 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 25534.1 will
permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
3. I certify that in the performance of the work for which this permit is issued,[ Health&Safety Code,Section 25532(x)should I store or handle hazardous
shall not employ any person.in any manner so as to become subject to the materlai.Additiomdty,should 1 ase equipment or devices which emft hazardous
air contaminants es 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 Cupertinorrnicipal Code,Chapter 9.12 and
exemption,I become subject to the Worker's Compensation provisions of the the Health&Safety Code,Sectio 2 05,25533, d 25534.
Labor Code,I nest forthwith comply with such provisions or this permit shall
be deemed revoked. Owner or authorized agent:
APPLICANT CERTIFICATION Data:06-18-2018
I certify that I have read this application and sate that the above Information is I LENDINGAGENCY
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,Section 9.18. 1 understand my plans shall be used as public records.
Licensed
Signature
Data 06-18-2016 Professional