B-2018-0526 REV#3 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS; CONTRACTOR: PERMIT NO:B-2018-0526
7495 PROSPFCT RD CUPERTINO,CA 95014-5241(366 15 053) OWNER/BUILDER
OWNER'SNAME: DATE ISSUED:03/29/2018
OWNER'S PHONE: PHONE NO:
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class Lie.#
Contractor OWNER/BUILDER Date XBLDG XELECT XPLUMB
I herebytl'firm that I am licensed under the provisions of Chapter 9 —MECH X RESIDENTIAL_COMMERCIAL
I P (cmnmenenig
with Section 7000)of Division 3 of the Business&Professions Code and that my
license is in fall force and effect. JOB DESCRIPTION:
KITCHEN REMODEL(144 ST.);PANEL UPGRADE(200 AMPS)
I hereby affirm under penalty of perjury one of the following two declarations: REV#I-REMODEL 2 BATHROOMS(72 SF);NEW LATERAL CLEAN-
r. I have and will maintain n certificate of consent to self-insure for Worker's OUTS HOUSE AND PROPERTY LINE;BURY EXISTING WATER LINE
Compensation,as provided for by Section 3700 of the Labor Code,for the -ISSUED 4-9-2018
performance of the work for which this permit is issued. REV#2-RE-STUCCO(930 SF)-ISSUED 4/24/2018
2. 1 have and will maintain Worker's Compensation Insurance,as provided for by REV#3-REPLACE WINDOWS(2)LIKE FOR LIKE TO MEET
Section 3700 of the Labor Code,for the performance of the work for which this EGRESS-ISSUED 8-7-2018
Permit is issued.
Sq.Rt Floor Area: Vnluntlan:$49000,00
APPLICANT CERTIFICATION
certify that have read this application and stale that the above
information is correct.I agree to comply with all city and county ordinances APN Number: Occupancy Type:
and state laws relating to building construction,and hereby authorize 366 15 053
representatives of this city to enter upon the above mentioned property for
Inspection purposes. (We)agree to save indemnify and keep harmless the
City of Cupertino against liabilities,judgments,costs,and expenses which PERMIT EXPIRES IF WORK IS NOT STARTED
may accrue against said City in consequence of the granting of this permit.
Additionally,the applicant understands and will comply with all non-point WITHIN 180 DAYS OF PERMIT ISSUANCE OR
source regulations per the Cupertino Municipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
Signature Date 08-7201$
Issued by:Abby Avende
Date:03/29/2018
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of the RF-ROOF
following two reasons: All roofs shall be inspected prim to any roofing material being installed.If root'is
t. 1,as owner of the property,or my employees with wages as their sole insist led 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(Sec.7044,Business&Professions Code)
2. 1,as owner of the property,am exclusively contracting with licensed Signatve of Applicant
contractors to construct the project(Sec.7044,Business&Professions Cade). Date:08-7-2018
I hereby affirm ander penalty of perjury one of the following three declarations:
i. I have and will maintain a Certificate of Consent m self-insure for Worker's ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
Compensation,as provided for by Section 3700 of the Labor Code,for the
2 performance of the work for which this permit is issued, HAZARDOUS MATERIALS DISCLOSURE
I have and will maintain Worker's Compensation Insumuco,as provided to,by I have read the Imzarchm s 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 25534.1 will
permit is issue& maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
s. I certify that in the performance of the work for which tris permit is issued,I Health&Safety Code,Section 25532(a)should I store o•handle hazardous
shall not employ any parson in any manner so as to become subject to the material.Additionally,should I use equipment or devices which emit hazardous
Worker's Componson..laws of California.If,atter making this certificate of air ecu tarnimult,ns defined by the Bay Area Air TorlJty,Management District I
exemption,I become subject to the Worker's Compensation provisions of the will"'ah"fir complhmce with the Cape"'
M ro t tkil ode,Chapter 9.12 and
Labor Code,I must forthwith comply with such provisions a this permit shall the Health&Safety Code,Sectio 25 5 5 3,and 25534.
be deemed revoked.
Owner or authorized agent:
APPLICANT-CERTIFICATIONDate:08-7-2018
I certify that I have read this application and state that the above Information is CONSTRUCTION LEN G 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 Ilabllilles,
judgments,costs,and expenses which may accrue against said City in Lender's Address
consequence of the granting of this ermIt.Additionally,the applicant understands
and will comply with all non-point rce regulations per the Cupertino Municipal ARCHI'TECT'S DECLARATION
Code,Section 9.18, „ 1 understand my plans shall be used as public records.
Signature Dale 08-7-2018 Licensed
Professional