B-2019-0410 CITY OF CUPERTINO BUILDING PERMIT
FBUILDING ADDRESS: CONTRACTOR:
10725 ORLINE CT CUI'ERTINO,CA 95014-4351(359 22 066) MJ12 CORP PERMIT NO:B-2019-0410
SAN JOSE,CA 95131
OWNER'S NAME:
DATE ISSUED:03/12/2019
OWNER'S PHONE:
PHONE NO:(408)955-9005
LICENSED CONTRACTOR'S DELL RATION BUILDIN
G PERMIT INFO:
License Class b.c-10 Lic.#DAIZZJ
Contractor MJ 12 CORP Date 03/31/2020 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:
/ 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.
APPLICANT CERTIFICATION Sq.Ft Floor Area: Valuation:$37000.00
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 359 22 066
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
may accrue against said City in consequence of the granting of this permit. EXPIRES IF WORK IS NOT STARTED
Additionally,the applicant understands and will comply with all non-point WITHIN 180 DAYS OF PERMIT ISSUANCE
source Cupertino Municipal Code,Section 9.18. ®R
180 DAYS FROM LAST CALLED INSPECTION.
Signature
Date 3/12/19 Issued by:Haley.McKee
OWNER-BUILDER DECLARATION Date:03/12/2019
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 beinginstall
ed.
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 If a roof is
compensation,will do the work,and the structure is not intended or offered for inspection. materials for
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:3/12/19
I hereby affirm under penalty of perjury one of the following three declarations:
1. I have and will maintain a Certificate of Consent to 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
performance of the work for which this permit is issued. HAZARDOUS MATERIALS DISCLOSURE
i. I have and will maintain Worker's Compensation Insurance,as provided for by I have read the hazardous materials requirements and
apter Section 3700 of the Labor Code,for the performance of the work for which this California Health&Safety Code,Sections 25505,25533 and 255395 of the
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
shall not employ any person in any manner so as to become subject to the material. Additionally,should I use equipment or devices which emit hazardous
Worker's Compensation laws of California. If'after making this certificate of air contaminants as defined by the Bay Area Air Quality Management District I exemption,I become subject to the Worker's Compensation provisions of the will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and
Labor Code,I must forthwith comply with such provisions or this permit shall the Health&Safety and 25534.
be deemed revoked.
Owner or authorized agent:
APPLICANT CERTIFICATION Date:3/12/19
I certify that I have read this application and state that the above information isCO ST U I N L D
NG correct.I agree to comply with all city and county ordinances and state laws I herebyaffirm that there is a construction nstruction lendingCy
agency y 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 DECL RATIO
Code,Section 9.18. 1 understand my plans shall be used as public records.
Signature Date 3/12/19 Licensed
Professional