B-2019-0224 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2019-0224
20360 CLIFDEN WAY CUPERTINO,CA 95014-4459(369 36 021) H T N
CONSTRUCTION INC
SAN JOSE,CA 95127
OWNER'S NAME: DATE ISSUED:04/22/2019
OWNER'S PHONE: PHONE NO:(408)318-8316
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class b Lic.#968413
Contractor H T N CONSTRUCTION INC Date 12/31/2019 X BLDG X ELECT —PLUMB
I hereby affirm that I am licensed under the provisions of Chapter 9(commencing X 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:
ADDITION FIRST FLOOR(999 SF);REMODEL KITCHEN(120 SF);
I hereby affirm under penalty of perjury one of the following two declarations: REMODEL(2)BATHROOMS(175 SF);CONVERT(75 SF) GAR;
have and will maintain a certificate of consent to self-insure for Worker's REMODEL OTHER(1423 SF); (N)PORCH(174 SF);RELOCATE
ompensation,as provided for by Section 3700 of the Labor Code,for the FURNACE(ATTIC);(N)AC UNIT;FULLY SPRINKLER HOUSE
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: 1074 Valuation:$364000.00
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'I�pe:
and state laws relating to building construction, and hereby authorize 369 36 021 R-3(Alternate Materials)
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 s Mrd City in consequence of the granting of this permit. WITHIN 180 DAY
Additionally,the apple nt understands and will comply with all non-point S OF PERMIT ISSUANCE OR
source regulations Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
Signature ,. Date 4/22/19 Issued by. Haley McKee
Date:04/22/2019
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)
2. I,as owner of the property,ani exclusively contracting with licensed Signature of Applicant:
contractors to construct the project(Sec.7044,Business&Professions Code). Date:4/22/19
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
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 equk ment 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 rea Air Quality Management District I
Worker's Compensation laws of California. If,after making this certificate of will maintain compliance with the Cuper ino Municipal Code,Chapter 9.12 and
exemption,I become subject to the Worker's Compensation provisions of the the Health&Safety
APPLICANT CERTIFICATION
Date:4/22/19
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 4/22/19 Professional