B-2018-0775 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2018-0775
10092 MANN DR CUPERTINO,CA 95014-1138(326 19 004) ROBERT LEWIS HALL
JR
CAMPBELL,CA 95008
OWNER'S NAME: DATE ISSUED:05/07/2018
OWNER'S PHONE: PHONE NO;(408)238.7178
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class C20 Lia#669870
Contractor ROBERT LEWIS HALL JR Dale 04/30/2019 X BLDG_ELECT_PLUMB
1 hereby affirm that I am licensed under the provisions of Cha ter 9(commencing MECH X RESIDENTIAL_COMMERCIAL
with Section 7000)of Division 3 of the Business&Professions Code and that my
license is in fall force and effect. JOB DESCRIPTION:
I hereby affirm under penalty of perjury one of the following two declarations: INSTALL NEW AC UNIT(LOCATED BACKYARD)
n. 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.
I have and will maintain Worker's Compensation Insurmce,as provided for by
Section 3700 of the Labor Code,fr the performance of the work for which this _
permit is issued. Sq.IT Fluor Are.: Valuation:,$5900.00
APPLICANT 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 326 19 004
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 regulatioTeth Cupertino Municipal Code,section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
Data 05-07-2018 Issued by:Kim Dunbar
Date:05/07/2018
OWNER-BUILDER DECLAIiAT10N
I hereby afltrm tont I am exempt from the Contractor's License Law for one ol'theR'ROOFS•
following five reasons: All roofs shell be inspected prior to any roofing material being installed fa roof is
r. I,as owner lithe 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(Sec.7044,Business&Professions Code)
z 1,as owner of the property,am exclusively contracting with licensed Signature of Applicant:
contractors to consuuct the project(Sce.7044,Business&Professions Corte), Date:05-07-2018
1 hereby affirm under penalty at perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
1. 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
x. 1 have and will maintain Worker's Compensation insurance,as provided for by 1 lurve rend the hazm thus matcrlots 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 Cuperthm Min ellen Code,Chapter 9.12 and the
a. 1 certify that in the performance of the work for which this permit is issued,I Health&Safer),Code,Section 25532(n)should I store or handle hazardous
shall not employ any person in any manner so as to become subject to the matcerial.Addltionally,should I use equipment or devices which emit hazardous
contaminants
as 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 Cupertino Municipal Code,Chapter 9.12 and
exemption,I become subject to the Worker's Compensation provisions of the the Heatth&Safety Cad cti 2 505, 33,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:05-07-2018
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 regulations per the Cupertino Municipal ARCHITECT'S DECLARATION
Code,Section 9.18. 1 understand my plans shall be used as public records.
SignatureLicensed
Data 05-07-2018
Professional