B-2018-1359 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2018-1359
10109 JUDY AVE CUPERTINO,CA 95014-3522(375 07 05 1) Hart Suejane And Kong-
yen 408-568-0616
20846 Dunbar Dr
Cupertino,CA 95014-
1802
OWNER'S NAME: DATE ISSUED:08/13/2018
OWNER'S PHONE: PHONE NO:None
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class Lic.#
Contractor Hen Suejane And Kong-yeu 408-568-0616 Date X BLDG X ELECT_PLUMB
I hereby affirm that I am licensed ander the provisions of Chapter 9(commencing MECH X RESIDENTIAL_COMMERCIAL
with Section 7000)of Division 3 of the Brines&Professinna Code and that my
license is in full force and effect. JOB DESCRIPTION:
(N)TEMPORARY POWER POLE-(120 AMP)
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 far 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. I have and will maintain Worker's Compensation insurance,as provided for by
Section 3700 of the Labor Code,for the Perot mance of the work for which this
permit is issued, Sq.Et Fluor Arca: Valuation:$800.00
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 Typo:
and state laws relating to building construction,and hereby authorize 17507 051
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 OB/1312018 Issued by:Jasmine Archbold
Date:08/13/2018
OWNER-BUILDER DECLARATION
I hereby affirm that 1 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 rooting material being installed.If e roof i5
1. I,as owner of the property,o 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 Dot intended or offered for inspection.
sale(Sec.7044,Business&Professions Cade)
as owner of the property,am exclusively contracting with licensed Signature ofApplicaur.
contractors to construct the project(See.7044,Business&Professions Code). Date,08/13/2018
I hereby affirm under penalty of perjury one of the following three dart rarimn: ALL ROOF COVERINGS 7'O BE CLASS"A"OR BETTER
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,for the
performance of the work for which this permit is issued. HAZARDOUS MATERIALS DISCLOSURE
e. 1 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 the performance of the work for which this California Health&Safety Code,Sections 25505,25533,and 25534.f will
permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and rhe
a. 1 certify that in the performance of the work for which this permit Is issued,I Health&Solely Code,Section 25532(x)should I store or handle hazardous
material.Additionally,should I use equipment or devices which emit hazardous
shall not employ any person in any manner so as to become subject to the
air contaminants as defined by the Bay Area Air Quality Management District I
Worker's Compensation laws o£Califonia.If,ager making this certificate of will maintain compliance with the Cupertino Municipal Cade,Chapter 9.12 and
exemption,I become subject to the Wo{cer's Compensation provisions of the the Health&Safety Cade,Sections 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:0811312018
1 certify that I have read this application and state that the above information Is CONSTRUCTION LEN HNG AGENCY
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 ARCHI'll""S I7 ECI ARATION
Code,Section 9.18. 1 understand my plans shall be used as public records.
Licensed
Signature Data 08/13/2018