B-2018-1367 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2018-1367
10050 FIRWOOD DR CUPERTINO,CA 95014-2640(342 33 046) Rosenbladt Nina
10050 Firwood Dr
Cupertino,CA 95014-
2640
OWNER'S NAME: DATE ISSUED:08/13/2018
OWNER'S PHONE: PHONE NO:
LICENSED CON'TRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class Llc.#
Contractor Rosenbladt Nina Date X BLDG_ELECT—PLUMB
1 hereby affirm that f am licensed tinder 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 tad effect. JOB DESCRIPTION:
KITCHEN REMODEL-(140 SF)
I hereby affirm under penalty of perjury one of the following two declarations:
t, 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.
s. Ihave and will maintain Worker's Compensation Insurance,as provided for by
Section 3700 of the Labor Cade,for the performance of the work for which this
permit is issued. Sq.Ft Floor Arca: Valuation:$25000.00
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 34233 046
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 9.1 S. 180 DAYS FROM LAST CALLED INSPECTION.
Signature Date 08/131201 8 Issued by:Jasmine Archbold
Date:08/13/2018
OWNER-BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractor's License Law for one of the RE-ROOFS,
following t—raitamu: All roofs shall be inspected prior to any roofing material being installed.If a.of is
r. 1,as owner of the property,or my employees with wages as then sole installed without first obtaining an inspection,1 agree to remove all new materials for
ompensation,will do the work,and the structure is not intended or offered for inspection.
Usale(Sce.7044,Business&Professions Code)
1,as owner of the property,am exclusively contracting with licensed Signature ofApplicanb
contractors to construct the project(See.7044,Business&Professions Code). Date:08/13/2018
1 hereby affirm order penalty of perjury one airline following three declarations: ALL ROOF COVERINGS 7'O BE CLASS"A"OR BETTER
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. HAZARDOUS MATERIALS DISCLOSURE
x. I have and will maintain Worker's Compensation Insurance,as provided for by I have rend the I nzardous materials requirements under Chapter 6.95 oftlrc
Section 3700 of Bre Labor Code,for die performance of the work for which this California health&Safety Code,Sections 25505,25533,and 25534.I will
permit is issued. m aintain compliance with the Cupertino Municipal Code,Chapter 9.12 mrd the
s, I certify that in die performance of the work for which this permit is issued,I Health&Safety Code,Section 25532(x)should I store or handle hazardous
And not employ any person in any manner so as to become subject to the rurrterial.Additionally,should 1 use equipment or devices which emit hazardous
or contaminants as defined by the Bay Area Air Quality Management District I
Worker's Compensation laws ofCrlifrml..If,after making this certificate of will maintain eomplImer with the Cupertino Municipal Code S,haptar 9.12 and
exemption,I become subject to the Worker's Compensation provisions of the the Health&Safety 5534.
Labor Code,I must forthwith comply with such provisions or this permit stall
be deemed revoked. Owner or authorized age t`
APPLICANT CRRTIFICATION Date:08113/22_,8113/2016
I certify that I have read this application and slate that the above information is C NSTRUCTIo LE DI C AGENCY
correct. agree to comply with all city and county ordinances and state laws hereby affirm that t ere is a cousin ctlon lending agency for the performance
relating to building construction,and hereby authorize representatives of this city of work's for which this pe[p�LCjs, ued(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 w tli al non-point source regulations per the Cupertino Municipal ARCHITECT'S DECLARATION
Code,Section
/ Date 08/13/2018 Licensed
Professional