B-2018-0631 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2018-0631
10589 CULBERTSON DR CUPERTINO,CA 95014-3505(375 36 022) SUCCESSFUL
CONSTRUCTION INC
FREMONT,CA 94538
OWNER'S NAME: DATE ISSUED:08/14/2018
OWNER'S PHONE: PHONE NO:(
LICENSED CONTRAC'TOR'S DECLARATION BUILDING PERMIT INFO:
License Class B Lic.4913612
Contractor SUCCESSFUL CONSTRUCTION INC Date 07/3112020 X BLDG—ELECT_PLUMB
1 hereby (firm that I nm licensed under the visions of Chapter 9 _MECH X RESIDENTIAL_COMMERCIAL
n pre p (commencing
with Section 7000)of Divislon 3 of the Business&Professions Code and that my
license is in full force and effect. JOB DESCRIPTION:
NEW 2 STORY SFD-(1928 SF)ATTACHED CAR(400 SF)PORCH(2)
1 hereby affirm under penalty of perjury one of the following two declarations: (407 SF)
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
3700 of the Labor Code,for the performance of the work for which tH8
permit is issued. Sq.Ft Floor Area:1928 Valuation:$256080.00
APPLICANT CERTIFICATION
I certify that I have read this applicallon 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 375 36 022 R-3(Custom)
representatives of line 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,casts,and expenses which PERMIT EXPIRES IF WORI{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
rtthe
eCCupertino Municipal code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
Signature�( �/" Date 08/14/2018 Issued by:.lasmine Archbold
Date:08/14/2018
OWNER-BUILDER DECLARATION
1 hereby affirm that I am exempt rrom tine Contractor's License Law 1'or one of me RE-ROOFS:
following two reasons: All roofs shelf be inspected prior to any mmF g material being installed.If.roof is
t. 1,as owner of the property,or my employees with wages as their sole installed without first obtaining an inspection,1 agree to remove n1I new materials for
compensation,will do the work,and the shucture is not intended or offered for inspection.
set.(Scc.7044,Business&Professions Code)
x. 1,as owner of the property,am exclusively contracting with licensed Signature ofApplieaan
contractors to construct the project(Sm.7044,Business&Professions Code), Date:08/14/2018
I hereby affirm under penalty of perjury one of the]'allowing three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
r, 1 have and will maintain a Certificate of Conscnt to self-insure for Worker's
Compensation,as provided for by Section 3700 of the Labor Code,for the
per of the work for which this permit is issued. HAZARDOUS MATERIALS DISCLOSURE
I, I 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 die 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
s. I certify that in the performance of the work for which this permit is issued,I n health&Solely Code,Section 25532(a)should 1 store or linndle hazardous
shall not employ manner so as to become sub'ect to the material.Additionally,should 1 use equipment or devices which emft hozardaus
p y any person in any m .I it contaminants as defined by the]try Are.Air Qualfty Management District I
Worker's Compensation laws of Culiforufa.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 provisious of the the Health&Safety Code,Sections 25505,25533,and 25534.
Labor Cade,I must forthwith comply with such provisions or this permit shall
be deemed revoked Owner or authorized agent: /
APPLICANT CERTIFICATION Data:08/14/2018
I certify that I have read this application and state that the above information is CONSTRUCTION i FNDTNG AGNi -
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 Al2CHl'f'EC'1"S DECLARATION
Code,Section 9.18. 1 understand my plans shall be used as public records.
Signature Date 08!14/2018 Licensed
Professional