B-2018-1070 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2018-1070
19731 LA MAR DR CUPERTINO,CA 95014-3308(369 l0 022) A-I HOME REPAIRS
INC
SAN JOSE,CA 95123
OWNER'S NAME: DATE ISSUED:06/26/2018
OWNER'S PHONE: PHONE NO:(
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class B Lic.#921651
ConlractorA-1 HOME REPAIRS INC Date 09/30/2018 X BLDG_ELECT_PLUMB
I hereby affirm that I nm licensed under the provisions of Chapter 9(commencing MECH X RESIDENTIAL_COMMERCIAL
with Section 7000)of Division 3 of the Business&Professions Cade and that my
license is to fall force and effect. JOB DESCRIPTION:
REMODEL KITCHEN LIKE FOR LIKE-(144 SF)
I hereby affirm under penalty of perjury one of the following two declarations:
1. I have and will maintain a certificate of consent to self-insmro 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,
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 fm which this
permit is issued, Sq.Ft Flom Area: Valnutimr:512000.00
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 state laws relating to building construction,and hereby authorize 369 10 022
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 accru ]appli
d City in consequence of the granting of this permit. WITHIN 180 DAYS OF PERMIT ISSUANCE OR
Addition y,the int u stands and will comply with all non-point
source Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
Signature Date 06-26-2018 Issued by:Kim Dunbar
Date:06/26/2018
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from 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
r. 1,as owner of the 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. I,as owner of the property,an,exclusively contracting with licensed Signature ofApplicanC
contractors to construct the project(Sec.7044,Business&Professions Code). Date:06-26-2018
I hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTERr. I have and will maintain a Certificate of Consent to self-insure fin oWorker's
Compensation,as provided for by Section 3700 of the Labor Cade,for the
performance of the work for which this permit is issued. HAZARDOUS MATERIALS DISCLOSURE
z. 1 have and will maintain Worker's Compensation lummi ce,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 andthe
s. I certify that in lire performance of the work for which this permit is issued,I health&Safety Code,Section 25532(x)s I store or handle Imzardons
shall not employ an person in an o as to become subject to tlne material.Additionally,should I use u' nest or evices which on hazardous
p y y pe y manner s J air contaminants as defined h• ce Btny ea Air Qu lily Mnnngemenf District[
Worker's Compensation laws of California.If,after making this certificate of will maintain compliance wit the
Cap
pert no Mnniei al which
Chapter 9.12 and
exemption,I became subject to the Worker's Compensation provisions of the the Health&Safef C ,Sect'ns 25505, 5533,and 25534.
Labor Code,1 must forthwith comply with such provisions or this permit shall
be deemed revoked Owner or authorized agent:
APPLICANT CERTIFICATION Data:06-26-2018.
I certify that I have read this application and state that the above information is C N.TR T 42LENDINACINCY
correct.I agree to comply with all city and county ordinances and state laws I hereby affirm that there is a construction lending a ency for the performance
relating to building construction,and hereby authorizerepresentatives 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 kee armless the City of Cupertino against liabilities,
I ,an xpense hlch may accrue against said City in Lender's Address
censer
ce oft ranting of thi ermil.Additionally,the applicant understands
and will
comply with ll non-point so rce regulations per the Cupertino Municipal A11CH1'I'EC'1"S llECLARATION
Cotle,Sectio .8. 1 understand my plans shall be used as public records.
Signature Date 06-26-2018 Licensed
Professlonal