D-2018-0023 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO;D-2018-0023
10589 CUL13ERTSON DR CUPERTINO,CA 95014-3505(375 36 022) SUCCESSFUL
CONSTRUCTION INC
FREMONT,CA 94538
OWNER'S NAME: DATE ISSUED:09/08/2018
OWNER'S PHONE: PHONE NO:(
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class B Lio.#913612
Contractor SUCCESSFUL CONSTRUCTION INC Date 07131/2020 —BLDG_ELECT_PLUMB
1 hereby affirm that f am licensed under the provisions at'Chapter 9(commencing MECH X RESIDENTIAL_COMMERCIAL
with Section 7000)of Division 3 of the Business&Professions Code and that my
license Is Lt tall force and effect. JOB DESCRIPTION:
DEMO 1-STORY SINGLE FAMILY DWELLING-(1130 SF)&
I hereby affirm under penalty of perjury one of the following two decim•atious: DETACHED GAR(225 SF;DEMO SHED-(80SF)
haw 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.Ft Flom•Area: Valuation;$20000.00
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 375 36 022
representatives of this city to enter upon the above refloated property for
inspectlon purposes. (We)agree to save Indemnify and keep harmless the
City of Cupertino against Ilabilitles,judgments,costs,and expenses which PERMIT EXPIRES IF WORT{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 QBl0812018 Issued by:Jasmine Archbold
Date:08/08/2018
OWNER-BOILDER DECLARATION
I hereby affirm that I ant exempt t'rom the Contractor's License Law for one m the RE-ROOFS:
following two reasons: All roofs shall be inspected prior to any rooting material being installed,If a roof is
1. I,as owner of the property,or my employees with wages m their sole installed without first obtaining an inspection,I agree to remove all new materials for
oompensatian,will do the work,and the structure is not intended or offered for inspection.
sale(Sec,7044,Business&Professions Cade)
x 1,as owner of the property,am exclusively contracting with licensed Signature of Applicant:
contractors to construct the project(Sec.7044,Business&Professions Code). Data:98108/2018
1 hereby affirm under penalty of perjury one of the following three declarations: ALL 1200E COVERINGS TO BE CLASS"A"OR BETTER
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. HAZARDOUS MATERIALS DISCLOSURE
z. I have and will maintain Worker's Compensation Insurance,as Is for by I have read the hazardous model his requirements under Chapter 6.95 of the
Section 3700 of the Labor Code,for the performance of the wonI,for which this California Health&Safety Code,Sections 25505,25533,and 25534.I will
permit is issued. matntat.compliance with the Cupertino Municipal Code,Chapter 9.12 and the
I. I certify that in the performance of the work far which this permit is issued,I Health&Safety Code,Section 25532(x)should I stare or handle hazardous
shot[not employ any person in any national so as to become subject to the material.Additionally,should I use equipment a,-devices which emit hazardous
or
contaminants as defined by the Bay Area Air Quality Management District I
Worker's Compensation laws of California.If,ager making this cerli}icale of will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and
exemption,l become subject to the Worker's Compensation provisions of the the Health&Safety Code,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 CEIi'1'IFICA't'ION Date:08!06/2018
I certify that I have read this application and slate that the above information is CON STRUC ON LENDING A.. Q'-
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 ARCHITECT'S DECLARATION
Code,Section 9.18. 1 understand my plans shall be used as public records.
Signature Date 08/08/2018 Licensed
Professional