9110025CITY OF CUPERTINO BUILDING PERiMIT
BUILDING ADDRESS: 21422 ELM CT
CONTRACTOR: FIVE STAR WINDOWS
PERMIT NO: 09110025
OWNER'S NAME:
CAMPBELL, CA 95008
PHONE NO: (408)370-3331
❑ LICENSED CONTRACTOR'S DECLARATION
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BUILDING PERMIT INFO: BLDG ELECT PLUMB
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License Class �t�� �'T Lic.
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Contractor. \ Date_._ 5101
MECH RESIDENTIAL COMMERCIAL
1 hereby affirm that I am licensed under the provisions of Chapter 9
JOB DESCRIPTION:WNDOW REPLACEMENT
(commencing with Section 7000) of Division 3 of the Business & Professions
Code and that my license is in full force and effect.
I hereby affirm under penalty of perjury one of the following two declarations:
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
Sq. Ft Floor Area:
Valuation: $14300
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
APN Number: 36201014.00
Occupancy Type:
permit is issued.
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is
PERMIT EXPIRES IF WORK IS NOT STARTED
correct. I agree to comply with all city and county ordinances and state laws relating
to building construction, and hereby authorize representatives of this city to enter
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
upon the above mentioned property for inspection purposes. (We) agree to save
180 DAYS FROM LAST CALLED INSPECTION.
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
costs, and expenses which may accrue against said City in consequence of the
granting of this permit. Additionally, the applicant understands and will comply
Issued �� Date://
with all non-point source regulations per the Cupertino Municipal Code, Section
9.18.
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RE-ROOFS:
All roofs shall be inspected prior to any roofing material being installed. If a roof is
El �! OWNER-BUILDS ECLARATION
installed without first obtaining an inspection, I agree to remove all new materials for
inspection.
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons:
Signature of Applicant: Date:
1, as owner of the property, or my employees with wages as their sole compensation,
will do the work, and the structure is not intended or offered for sale (Sec.7044,
Business & Professions Code)
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
1, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec.7044, Business & Professions Code).
HAZARDOUS MATERIALS DISCLOSURE
I hereby affirm under penalty of perjury one of the following three
I have read the hazardous materials requirements under Chapter 6.95 of the
declarations:
California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain
1 have and will maintain a Certificate of Consent to self-insure for Worker's
compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health &
Compensation, as provided for by S-ection 3700 of the Labor Code, for the
Safety Code, Section 25532(a) should I store or handle hazardous material.
performance of the work for which this permit is issued.
Additionally, should I use equipment or devices which emit hazardous air
I have and will maintain Worker's Compensation Insurance, as provided for by
contaminants as defined by the Bay Area Air Quality Management District I will
Section 3700 of the Labor Code, for the performance of the work for which this
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
Health & Safety Code, Sections 25505, 25533, and 25534.
permit is issued.
I certify that in the performance of the work for which this permit is issued, I shall
Owner- : / c�
not employ any person in any manner so as to become subject to the Worker's
Date: (%
Compensation laws of California. If, after making this certificate of exemption, I
become subject to the Worker's Compensation provisions of the Labor Code, I must
CONSTRUCTION LENDING AGENCY
forthwith comply with such provisions or this permit shall be deemed revoked.
1 hereby affirm that there is a construction lending agency for the performance of work's
for which this permit is issued (Sec. 3097, Civ C.)
APPLICANT CERTIFICATION
Lender's Name
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 and state laws relating
Lender's Address
to building construction, and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We) agree to save
ARCHITECT'S DECLARATION
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
costs, and expenses which may accrue against said City in consequence of the
I understand my plans shall be used as public records.
granting of this permit. Additionally, the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code, Section
Licensed Professional
9.18.
Signature Date