B-2018-1118 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2018-1118
10181 MACADAM LN CUPERTINO,CA 95014-2176(36901057) QUARTZ
CONSTRUCTION
SAN.JOSE,CA 95148
OWNER'S NAME:WITT DAVID R TRUSTEE DATE ISSUED:07/03/2018
OWNER'S PHONE: PHONE NO:(408)966-2704
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class B Lie.#1003436
Contractor QUARTZ CONSTRUCTION Date 05131/2019 X BLDG ELECT_PLUMB
1 hereby offirm that I am 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 in full force and effect. JOB DESCRIPTION:
SECOND STORY BATH REMODEL(72 SF)
I hereby offirm under penalty of perjury one of the following two declarations:
r. 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.
G 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 this
permit is issued Sq.Ft Floor Area: Valuation:$15000.00
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 36901 057
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 h® anting of this permit.
Additionally,the applicant understands an I compply with all non-point WITHIN 180 DAYS OF PERMIT ISSUANCE OR
source regulations per the Cupertino KuNdleal C rte,Section 9.18, 180 DAYS FROM LAST CALLED INSPECTION.
Signature Date 7-3-2018 Issued by:Kim Dunbar
Data:07/03/2018
OWNER-BUILDER DECLARATION
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I hereby affirm that I am exempt from the Contractbr's._License Law for one of the HE-ROOFS
following two reasons: All roofs she 11 be inspected prior to any roofing material being installed.If roof is
n. 1,as owner of the property,or my employees with wages as their sole installed without first obtaining am inspection,I agree to remove all new materials for
compensation,will do the work,and the structure is not intended or offered for inspectimn.
sale(Sec.7044,Business&Professions Code)
z. I,as owner of the property,am exclusively contracting with licensed Signature ofApplican4
contractors to construct the project(Sec.7044,Business&Professions Code). Datc:7-3-2018
Thereby afl7rm underpenal o perjury one ofTrFall ra vihreeh ions: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
n. Ihave 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
2. 1 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
n. I certify that in the performance of the work for which this permit is issued,I health&Safety Code,Section 2553200 should 1 store or handle hazardous
shall not employ any person in any manner so as to become subject to the motorial.Additionally,should I use equipment or devices which emit hazardous
air contaminants as defined by the Bay Area Ah•Qtmlity Mnn meat District I
Worker's Compensation laws of California.If,after making this certificate of will maintain compliance with the Cupertino Municipal hapten 9.12 and
exemption,I become subject to the Worker's Compensation provisions of the the Health&Safety Code,Sections 25505, 3,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:7-3-2018
I certify that I have read this application and state that the above information Is CONSTRIIC'f10N LF.NLIING 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.
Signature Date?3-2018 Licensed
Professional