B-2018-1107 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2018-1107
21697 LOMITA AVE CUPERTINO,CA 95014-5910(35717092) OWNER/BUILDER
OWNER'S NAME:KA JEANNIE YOON AND LEE YONG J DATE ISSUED:07/02/2018
OWNER'S PHONE: PHONE NO:
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class Lic.#
Contractor OWNER/BUILDER Date XBLDG—ELECT—PLUMB
1 hereby affirm that 1 am licensed under the provisions of Chapter 9(commencing —MECH X RESIDENTIAL_COMMERCIAL
with Section 7000)of Division 3 of the Business&Professions Code and that my
license is in full force and effect. JOB DESCRIPTION;
SECOND FLOOR BATH REMODEL-(150 SF)
I hereby affirm under penalty of perjury one of the fallowing two declarations:
1. I have and will maintain a certificate of consent to self-insure for Worker's
Compensation,as provided for by Section 3700 of lire Labor Code,for the
performance of the work for which this permit is issued.
z, 1 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:$6000.00
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above AIN Number: Occupancy
information is correct.I agree to comply with all city and county ordinances panty Type:
and slate laws relating to building construction,and hereby authorize 357 17 092
representatives of this city to enter upon the above mentioned properly 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 Data 7-2-2018 Issued by:Kim Dunbar
Date:07/02/2018
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,l agree to remove all hew materials for
compensmion,will do the work,and the strvcmre is not intended or offered for inspection.
sale(Sec.7044,Business&Professions Code)
z. I,as owner ofthe property,am exclusively contracting with licensed Signature of Applicant:
contractors to construct the project(Sec,7044,Business&Professions Code). Date;?2-2018
1 lu•eh y-rBro m nd aperfult3�1TIoujury ane of the followingALLROOF-COVERINGS`PO-Bl;CLASS-A"OR-BETTER
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 Cade,he the
performance ofthe work for which this permit is issued. HAZARDOUS MATERIALS DISCLOSURE
z. 1 have and will maintain Worker's Compensation Insurance,as provided£or by 1 have read the hazardous materials requirements under Chapter 6.95 of the
Section 3700 ofthe Labor Code,for the performance of the work for which this Gdifornin Health&Safety Code,Sections 25505,25533,and 25534.I will
permit is issued. malntaln compliance with the Cupertino Municipal Cade,Chapter 9.12 and the
�CtI certify that in the performance ofthe work for which this permit is issued,I Health&Safety Corte,Section 25532(x)should I store or handle hazardous 11 a shall not employ any person in any manner se as to become subject to the material.Additionally,should I use equipment or devices which emit hazardous
CC air contaminants as defined by the Bay Area Air Quality Management District 1
Worker's Compensation laws of California.If,after making this certificate of will maintain compliance with the Cupertino Mmdclpal Code,Chapter 9.12 and
exemption,I become subject to the Worker's Compensation provisions of the the health&Safety CodeSection„ s 25505,25533,and 25534.
Labor Code,I most forthwith comply with such provisions or this permit shall
be decimal revoked. Owner or authorized agent:
APPIICANT CERTIFICATION Oct.:7-2-2018
I certify that I have read this application and state that the above Information Is CONSTRUCTION LENI3ING AGF,NCYLENDING AGF,NCY
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
Date -7 2-2018 Professional