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B-2019-0071 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: CONTRACTOR: PERMIT NO: B-2019-0071 21104 WHITE FIR CT CUPERTINO, CA 95014-4234 (359 05 086) BROTHERS HOME IMPROVEMENT INC ROCKLIN, CA 95765 OWNER'S NAME: DATE ISSUED: 01/10/2019 OWNER'S .PHONE: PHONE NO: (916) 791-9170 LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: License Class B, C17 Lic. #699009 Contractor BROTHERS HOME IMPROVEMENT INC Date 11/30/2020 X BLDG — ELECT — PLUMB I hereby affirm that I am licensed under 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 and effect. JOB DESCRIPTION: INSTALL (9) WINDOWS LIKE FOR LIKE TO MEET EGRESS AND (1) I hereby affirm under penalty of perjury one of the following two declarations: PATIO DOOR 1. 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. 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: Valuation: $9789.00 APPLICANT CERTIFICATION 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 35905 086 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 p K the Cupertino Municipal Code, Section 9. 18. 180 DAYS FROM LAST CALLED INSPECTION. Signature Date 01/10/2019 Issued by: Jasmine Archbold Date: 01/10/2019 OWNER-BER DECLARATION I hereby affirm that I 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 roofing material being installed. If a roof is 1. I, as owner of the property, or 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 not intended or offered for inspection. sale (Sec.7044, Business & Professions Code) 2. I, as owner of the property, am exclusively contracting with licensed Signature of Applicant: contractors to construct the project (Sec.7044, Business & Professions Code). Date: 01/10/2019 I hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER 1. 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 2. I 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. I will permit is issued. maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the 3. I certify that in the performance of the work for which this permit is issued, I Health & Safety Code, Section 25532(a) 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 of California. If, after making this certificate of will maintain compliance with theC tin Municipal Code, Chapter 9.12 and exemption, I become subject to the Worker's Compensation provisions of the the Health & Safety de, ns 25505, 25533, and 25534. Labor Code, I must forthwith comply with such provisions or this permit shall be deemed revolted, Owner or authorized agent: APPLICANT CERTIFICATION Date: 01/10/2019 certify that I have read this application and state that the above information is CONSTRU ENDING 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 ARCHITECT'S DECLARATION Code, Section 9.18. I understand my plans shall be used as public records. Licensed Signature Date 01/10/2019 Professional