B-2018-0526 REV#1 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2018-0526
7495 PROSPECT RD CUPERTINO,CA 95014-5241(366 15 053) OWNER/BUILDER
OWNER'S NAME: DATE ISSUED:03/29/2018
OWNER'S PHONE: PHONE NO:
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class Lid.#
Contractor OWNERIBUILDER Date X BLDG X ELECT X PLUMB
I hereby affirm that I nm licensed tinder the provisions of Chapter 9(commencing MECH X RESIDENTIAL COMMERCIAL
with Section 7000)of Division 3 of flic Business&Professions Code and that my
license is in full force and effect. JOB DESCRIPTION:
KITCHEN REMODEL(144 S.F.);PANEL UPGRADE(200 AMPS)
I hereby offirm under penalty of perjury one of the following two declarations: REV#1-REMODEL 2 BATHROOMS(72 SF);NEW LATERAL CLEAN-
r. I have and will maintain a certificate of consent to self-insure for Worker's OUTS HOUSE AND PROPERTY LINE;BURY EXISTING WATER LINE
Compensation,as provided for by Section 3700 of the Labor Code,for the -ISSUED 4-9-2018
performance £the work for which this permit is issued.
2. 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 this
permit is issued. Sq.Ft Floor Area: Valuation:$40000.00
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above O
Number: ccu
information is correct.I agree to comply with all city and county ordinances AYN NumOccupancyType:
and state laws relating to building construction,and hereby authorize 366 15 053
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 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 regulations per the Cupertino Municipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
Signature Date 04-09-2018 Issued by:AbbyAAyende
Date:03/29/2018
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Cenu•actor's License Law for one of the RE-ROOFS:
following hvn rensons: All roofs shall be inspected prior to any roofing material being installed.If a roof is
s. 1,as owner of the property,or my employees with wages as their sole installed Without first obtaining an inspection,1 agree to remove all new materials for
compensation,will do the work,and the structure is not intended or offered for in portion.
under penalty of perjury one of the following three declarations: ALL 1200E COVERINGS TO BE CLASS"A"OR BETTERr. 1 have and will maintain a Certificate of Consent to sell'-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. 1 have and will maintain Worker's Compensation busurance,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
a. 1 certify that in the performance of the work for which this permit is issued,I Health&Safety Code,Section 25532(x)should I store or handle hazardous
material.Additionally,slmnld f use equipment or devices which emit hazardous
shall not employ any person in any manner so as to become subject to the ob.erial. dditi m defined by flue Bey Arca Air Quality Management District f
Worker's Compensation laws of California.If,atter making This certificate of willmme maintain compliance with the Cupertino Municipal Code,Clmpter 9.12 and
exemption,I become subject to the Worker's Compensation provisions of the the Health&Safety Code,Sections 25505,25533 and 25534.
Labor Cade,l must forthwith comply with such provisions or this permit shall _
be deemed revoked. O :
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
--'— Data 04-09-2018 Professional