B-2018-1196 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2018-1196
7523 DONEGAL DR CUPERTINO,CA 95014-5200(366 16 060) SANDIUM INC
SAN JOSE,CA 95134
OWNER'S NAME:Liu Rosa Y Trustee DATE ISSUED:07/16/2018
OWNER'S PHONE: PHONE NO:(408)994-9072
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class CC=20 Jr.#888149
Contractor SANDIUM INC Date 12131018 X BLDG ELECT_PLUMB
I hereby affirm that I am licensed under the provisions of Chapter 9(commencing X MECH X RESIDENTIAL_COMMERCIAL
with Section 7000)at'Divislon 3 of the Business&Professions Code and that my
license is in full force and effect, JOB DESCRIPTION:
ADD(N)AC UNIT-SIDE YARD
I hereby affirm 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.
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:$6500,00
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 366 16 060
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 regulatio 6 per the Cupertino Municipal Code,Section 9.18, 180 DAYS FROM LAST CALLED INSPECTION.
Slgnalure Date 07/16/2018 Issued by:Jasmine Archbold
Date:07/16/2018
OWNER-BUILDER DECLARATION
I hereby affirm first I or exempt from the Cmur.tm•'s License Law to,-are of theRE-ROOFS:
following two reasons: All roofs shall be inspected prim to any roofing material being installed.IIa roof a
u I,as owner of the property,or my employees with wages as their sole installed without first obtainingra inspection,1 agree to remove all new materials For
compensation,will do the work,and the snveture js not intended or offered far inspection.
sale(Sec.7044,Business&Professions Code)
z. 1,as owner of due property,am exclusively contracting with licensed Signature of Applicant
contractors to construct the project(See.7044,Business&Professions Code). Date:07/16/2018
1 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£or 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
I, I have and will maintain Worker's Compensation Insurance,as in 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 I certify that in the perfnnnauce ofthe work for which this permit is issued,I Health&Safety Code,Section 25532(a)should 1 store m•handle hazardous
shall not employ any person in any manner so as to become subject to the material'
onAdditionally,should I use equipment or devices which emit hazardous
air taminants as defined by the Bay Arca Air Quality Management District 1
Worker's Compensation laws of Califomia,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 u£the the Health&Safety Code,Se tions 25505,25533,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:Q7/16,2018
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 is.
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
Cade,Section 9.18. 1 understand my plans shall be used as public records.
Licensed
Signature Data 07116!2018
Professional