B-2018-1255 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2018-1255
22740 SAN JUAN RD CUPERTINO,CA 95014-3935(342 21 012) Kottke Nelson And
Amanda T
22740 San Juan Rd
Cupertino,CA 95014-
3935
OWNER'S NAME: DATE ISSUED:07/26/2018
OWNER'S PHONE: PHONE NO;
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class Lid.#
Contractor Kottke Nelson And Amanda T Dale X BLDG 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:
CONVERT DEN TO BEDROOM AND REMO VE A UTILITY SINK
I hereby afDrm under penalty of perjury one all fallowing two declarations: (CAPPED OFF IN WALL)
t. 1 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. -
x. 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.Et Floor Area: - Valuation:$600.00
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 stale laws relating to building construction,and hereby authorize .34221012
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 07/26/2018 Issued by:Jasmine Archbold
Date:07/26/2018
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of the RE-ROOFS:
1'
See.7044,Business&Professions Code)
z 1,as owner of the property,am exclusively contracting with licensed Signature ofApplicanc
contractors to construct the project(Sec.7044,Business&Professions Code). Dote:07/26/2018
I hereby affirm miner penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
r. I have and will maintain a Certificate of Consent to self-insure Its Worker's
Compensation,as provided for by Section 3700 of the Labor Code,for the
performance ofthe work far which this permit is issued. HAZARDOUS MATERIALS DISCLOSURE
z. I haw and will maintain Worker's Compensation Insurance,as provided for by I have read the hazardous mateials requirements under Chapter 6.95 of the
Section 3700 of the Labor Code,for the performance of the work for which this Colil'ormbr Health&Safety Code,Sections 25505,25533,aad 25534.1 vvill
permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
I certify that in the performance of the work for which this permit is issued,I Health&Safety Code,Section 25532(n)should 1 stare or handle hazardous
shall not employ any person in any manner so as to become subject to the material.Additionally,should I use equipment or devices which entft hazardous
air wntar dmets us defined by the Bay Area Ali-Quality Management District I
Worker's Compensation laws ofColilrond..If,atter making this eenificute of will maintain compliance with the Cape"Ino Municipal Code,Chapter 9.12 and
exemption,I become subject to the Worker's Compensation provisions of the the Health&Sat'ety
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 n1a,l I'PEC'P'S DECLARATION
Code,Section 9.18. 1 understand my plans shall be used as public records.
Signature Date 07/2612018 Licensed