B-2018-1267 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CON'T'RACTOR: PERMIT NO:B-2018-1267
18625 RALYA CT CUPERTINO,CA 95014-3823(375 25 005) OWNER/BUILDER
OWNER'S NAME: DATE ISSUED:07/27/2018
OWNER'S PHONE: PHONE NO:
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class Lic.#
Contractor OWNER/BUILDER Date XBLDG XELECT_PLUMB
I hereby affirm that I am licensed corder the provisions of Chapter 9(reconvertingMECH X RESIDENTIAL_COMMERCIAL
with Section 7000)of Divislon 3 of'the Business&Professions Code and that my
license Is in fall farce and effect. JOB DESCRIPTION:
PANEL UPGRADE(200 AMP)
I hereby affirm under penalty of perjury one ofthe 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 ofthe Labor Code,for the
performance of the work for which this permit is issued.
1. 1 have and will maintain Worker's Compensation Insurance,as provided for by
Section 3700 of the Labor Code,for the performance ofthe work for which this
permit is issued. Sq.Ft Fluor Aren: Valuation:$3000.00
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: Occupmoey Type:
and state laws relating to building construction,and hereby authorize 375 25 005
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 facilities,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 Dale 7/27/2018 Issued by:Kim Dunbar
Date:07/27/2018
OWNER-BUILDER DECLARA ION
I hereby affirm that I am exempt from the Contractor's License Law for one of the RL-ROOFS:
following two reasons: All roofs shall be inspected prior to any roofing material being installed.If e roof is
r. 1,as owner of tire 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(Sce.7044,Business&Professions Cade)
Q1,as owner of the property,am exclusively contracting with licensed Signature of Applicant:
contractors to construct the project(Sec.7044,Business&Professions Code). Date:7127/2018
1 hereby affirm under penalty of perjury one ofthe following three declarations: At I.,ROOF COVERINGS TO BE CLASS"A"OR BETTER
r. I have and will maintain a Certificate of Consent to self-insure for Worker's
Compenselion,as provided for by Section 3700 ol'the Labor Code,for the
per ofthe work fur which this permit is issued. HAZARDOUS MATERIALS DISCLOSURE
1. 1 have and will maintain Worker's Compensation Insurance,as provided far by 1 have read the hazardous materials requirements under Chapter 6.95 ofthe
Section 3700 ofthe Labor Code,for the performance of the work for which this California Health&Safety Cade,Sections 25505,25533,and 25534.I will
permit is issued. maintain compliance with the Cupertino Municipal Cade,Chapter 9.12 and the
a I certify that in the performance ofthe work for which this permit is issued,I Health&Safety Code,Section 255320)should I store or bundle haznrdons
shall not employ any person in any manner so as to become subject to the nurterfal.Additionally,should 1 use equipment or devices which emit hazardous
air conaminants us 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
er n M
with the Cupunicipal Code,Chapter 9.12 and
exemption,f become subject to the Worker's Compensation provisions ofthe the Health&S ifefy Cnde,
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 1 on-point source regulations per the Cupertino Municipal ARCHITECT'S DECLARATION
Code,Section 9.18 I understand my plans shall be used as public records.
Signature Date 7/27/2018 Licensed
Professional