B-2018-1361 CITY OF CUPERTINO BUILDING PERMIT
BUILDINGADDRESS: CONTRACTOR: PERMITNO:B-2018-1361
10197 DANUBE DR CUPERTINO,CA 95014-2141(369 49 001) OWNER/BUILDER
OWNER'S NAME: DATE ISSUED:08/13/2018
OWNER'S PHONE: PHONE NO:
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class Llc.#
Contractor OWNER/BUILDER Date XBLDG—ELECT_PLUMB
MECH X RESIDENTIAL COMMERCIAL
I hereby nl'Brur that I mm lNe sed render the previsions of Chapter 9(commencing — —
with Seaton 7000).f Division 3 of the Business&Professions Code moll Unduly
license is in full force and ef'f'ect. JOB DESCRIPTION:
KITCHEN REMODEL(100 SF)
I hereby al'urm under penalty of perjury one of the following two declarntions:
I 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.
1. I have 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 Floor Area: Whistle.:$25000.00
APPLICANT CERTIFICATION
I certify that I have read this a"fastion and state that the above Occupancy
information is correct.I agree to comply with all city and county ordinances APN NumType:
and state laws relating to building construction,and hereby authorize 369 49 001
representatives of this city to enter upon the above mentioned property for
inspection purposes. (We)agree to save[notarially 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 B-13-2018 Issued by:Kim Dunbar
Date:08/13/2018
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of the RE-ROOFS:
fall'.Yk�rg two reasons: All roofs shall be inspected prior to any roofing material being installed.If a roof is
s./ 1,as ow r of the property,ar my employees with wages as their .Is installed without first obtaining an inspection,I agree to remove all new materials for
�-1compensation,will do the work,and the structure is not intended or offered for inspection.
sale(See.7044,Business&Professions Code)
as owner of the property,am exclusively contracting with licensed Signature of Applicant
contractors to construct the project(Sec.7044,Business&Professions Code), Dote:8-13-2018
I batchl'firin mode•penally of perjury one of fire following three declarations: ALL ROOF COVERINGS TO 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
I have and will maintain Worker's Connpensation lusurance,as provided for by 1 hnve read the hazardous nmta9als requiremerts under Chapter 6,95 of the
Section 3700 of the Labor Code,for the performance of the weak for which this California Health&Safety Code,Sections 25505,25533,and 25534.f will
permit is issued, maintain compliance with the Cupertino Municipal Corte,Chapter 9.12 and the
1 certify that in the performance of the work for which[his permit is issued,I Health&Safety Code,Section 25532(a)should I stare or handle hazardous
-- shall not employ son hr an s to become subject to the material.Additionally,should I use equipment or devices which mitt hazardous
p y any per y manner son j air cantaminamts ns defined by the Bay Arco Air Quality Management District I
Worker's Compensation laws of California.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 provisions of the the Health&Safety Code,
Lobar Code,I must Forthwith comply with such provisions or this permit shallbe deemed revoked. Owner or authorized agent:
APPLICANT CERTIFICATION Date:8-13-2018
I certify that I have read this application and state that the above information is CONSTRUCTION LEN'ING 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 grantingof 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