B-2019-0470 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2019-0470
10313 BLANEY CT CUPERTINO,CA 95014-3123(369 32 015) OWNER BUILDER
OWNER'S NAME: DATE ISSUED:03/19/2019
OWNER'S PHONE: PHONE NO:
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class Lic.#
Contractor OWNER BUILDER Date X BLDG X 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:
REMODEL BATHROOM(63 SF);INSTALL ELECTRICAL TO SHED(6)
I hereby affirm under penalty of perjury one of the following two declarations: OUTLETS AND(2)LIGHTS
1. I have and will maintain a certificate of consent to self-insure for Worker's REV#1 -UPGRADE MAIN HOUSE PANEL(200 AMP)-ISSUED
Compensation,as provided for by Section 3700 of the Labor Code,for the 6/21/19
performance of the work for which this permit is issued. REV#2-LATERAL CONNECTION TO EXISTING LATERAL WITH
2. I have and will maintain Worker's Compensation Insurance,as provided for by NEW CLEAN-OUT AND CCTV INSPECTION-ISSUED 7-1-2019
Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued.
APPLICANT CERTIFICATION
certify that I have read this application and state that the above Sq.Ft Floor Area: Valuation:$8000.00
information is 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 upon the above mentioned property for 69 Number: Occupancy Type:
3
inspection purposes. (We)agree to save indemnify and keep harmless the 369 32 015
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 with all non-point PERMIT EXPIRES IF WORK IS NOT STARTED
source regulations per the Cupertino Municipal Code,Section 9.18. WITHIN 180 DAYS OF PERMIT ISSUANCE OR
Signature Date 7-1-2019 180 DAYS FROM LAST CALLED INSPECTION.
OWNER-BUILDER DECLARATION Issued by: SEAN HATCH
Date:03/19/2019
I hereby affirm that I am exempt from the Contractor's License Law for one of the
following two reasons:
1. I,as owner of the property,or my employees with wages as their sole RE-ROOFS:
compensation,will do the work,and the structure is not intended or offered for All roofs shall be inspected prior to any roofing material being installed.If a roof is
sale(Sec.7044,Business&Professions Code)
installed without first obtaining an inspection,I agree to remove all new materials for
2. I,as owner of the property,am exclusively contracting with licensed inspection.
contractors to construct the project(Sec.7044,Business&Professions Code).
Signature of Applicant:
I hereby affirm under penalty of perjury one of the following three declarations: Date:7-1-2019
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 ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
performance of the work for which this permit is issued.
2. 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 HAZARDOUS MATERIALS DISCLOSURE
permit is issued. I have read the hazardous materials requirements under Chapter 6.95 of the
3. I certify that in the performance of the work for which this permit is issued'I California Health&Safety Code,Sections 25505,25533,and 25534. I will
maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
shall not employ any person in any manner so as to become subject to the Health&Safety Code,Section 25532(a)should I store or handle hazardous
Worker's Compensation laws of California. If,after making this certificate of material. Additionally,should I use equipment or devices which emit hazardous
exemption,I become subject to the Worker's Compensation provisions of the air contaminants as defined by the Bay Area Air Quality Management District I
Labor Code,I must forthwith comply with such provisions or this permit shall will maintain compliance with the Cupertino Munici al Code,Chapter 9.12 and
be deemed revoked. the Health&Safety Code,
I certify that I have read this application and state that the above information is Owner or authorized agent:
V�
correct.I agree to comply with all city and county ordinances and state laws Date:7-1-2019
relating to building construction,and hereby authorize representatives of this city CONSTRUCTION LENDING AGENCY
to enter upon the above mentioned property for inspection purposes. (We)agree I hereby affirm that there is a construction lending agency for the performance
to save indemnify and keep harmless the City of Cupertino against liabilities, of work's for which this permit is issued(Sec.3097,Civ C.)
judgments,costs,and expenses which may accrue against said City in Lender's Name
consequence of the granting of this permit. Additionally,the applicant understands
and will comply with all non-point s urce regulations per the Cupertino Municipal Lender's Address
Code,Section 9.
I understand my plans shall be used as public records.
Signature Date 7-1-2019
Licensed
Professional
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2019-0470
10313 BLANEY CT CUPERTINO,CA 95014-3123(369 32 015) OWNER/BUILDER
OWNER'S NAME: DATE ISSUED:03/19/2019
OWNER'S PHONE: PHONE NO:
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class Lic.#
Contractor OWNER/BUILDER Date X BLDG X 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:
REMODEL BATHROOM(63 SF);INSTALL ELECTRICAL TO SHED(6)
I hereby affirm under penalty of perjury one of the following two declarations: OUTLETS AND(2)LIGHTS
1. I have and will maintain a certificate of consent to self-insure for Worker's REV#1 -UPGRADE,MAIN HOUSE PANEL(200 AMP)-ISSUED
Compensation,as provided for by Section 3700 of the Labor Code,for the 6/21/19
performance of the work for which this permit is issued.
2. 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:$8000.00
APPLICANT CERTIFICATION
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 369 32 015
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. 184 DAYS FROM LAST CALLED INSPECTION.
Signature Date 6/21/19 Issued by: SEAN HATCH
Date:03/19/2019
OWNER-BUILDER 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
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.
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:6/21/19
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
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
California Health&Safety Code Sections 25 0 2 '
Section 3700 of the Labor Code,for the performance of the work for which this Y 5 5, 5533,and 25534. I will
'
�--- maintain compliance with the Cupertino Municipal Code Chapter 9.12 and thepermit is issued.
` 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 QualityManagement District I
Worker's Compensation laws of California. If,after making this certificate of will g
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, 25534.
Labor Code,I must forthwith comply with such provisions or this permit shall
be deemed revoked. Owner or authorized agent: .
APPLICANT CERTIFICATION Date: 6/21/19
I certify that I have read this application and state that the above information is CONSTRUCTION LENDING 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. 1 understand my plans shall be used as public records.
' Licensed
Signature Date 6/21/19
Professional
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2019-0470
10313 BLANEY CT CUPERTINO,CA 95014-3123(369 32 015) OWNER/BUILDER
OWNER'S NAME: DATE ISSUED:03/19/2019
OWNER'S PHONE: PHONE NO:
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class Lic.#
Contractor OWNER/BUILDER Date X BLDG X 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:
REMODEL BATHROOM(63 SF);INSTALL ELECTRICAL TO SHED(6)
I hereby affirm under penalty of perjury one of the following two declarations: OUTLETS AND(2)LIGHTS.
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.
2. 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:$8000.00
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 69 Number: Occupancy Type:
3
and state laws relating to building construction,and hereby authorize 369 32 015
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 per the Cupertino Municipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
Signature Date Issued by: SEAN HATCH
Date:03/19/2019
OWNER-BUILDER 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)
z. 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:
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
1 certify that in the performance of the work for which this pen-nit 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
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 the Cup tino Municipal ode,Chapter 9.12 and
exemption,I become subject to the Worker's Compensation provisions of the the Health&Safety Code,
certify that I have read this application and state that the above information is CONSTRUCTION LENDING 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
I understand my plans shall be used as public records.
Licensed
Signature! Date
Professional