B-2017-0155 REV#1 PERMITEl
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS:
CONTRACTOR:
PERMIT NO: B-2017-0155
11801 DOROTHY ANNE WAY UNIT 6 CUPERTINO, CA (366 09 043)
OWNER'S NAME: CHANG LONG REALTY DEVELOPMENT LLC ET AL
DATE ISSUED: 10/03/2017
OWNER'S PHONE:
PHONE NO:
LICENSED CONTRACTOR'S DECLARATION
BUILDING PERMIT INFO:
License Class Lic. #
Contractor Date
X BLDG X ELECT —PLUMB
MECH X RESIDENTIAL COMMERCIAL
I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing
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with Section 7000) of Division 3 of the Business & Professions Code and that my
license is in full force and effect.
JOB DESCRIPTION:
REV#1 - INSTALL NEW PANEL (100 AMP); INSTALL NEW OUTLETS
I hereby affirm under penalty of perjury one of the following two declarations:
(24), RECESSED LIGHT (21)
i. I have and will maintain a certificate of consent to self -insure for Worker's
TO CLEAR CODE ENFORCEMENT: UNIT 6 (GARDENER'S
Compensation, as provided for by Section 3700 of the Labor Code, for the
COTTAGE) - DEMOLISH ADDITION, ROOF AND PORCH
performance of the work for which this permit is issued.
STRUCTURES (731 S.F.); RESTORE HISTORIC HIP ROOF
2. I have and will maintain Worker's Compensation Insurance, as provided for by
STRUCTURE AT MASTER BEDROOM (204 S.F.); (N) WINDOW IN
Section 3700 of the Labor Code, for the performance of the work for which this
LAUNDRY ROOM; (N) SIDING (774 S.F.); RESTORE COVERED
permit is issued.
PORCH AND STAIRS.
APPLICANT CERTIFICATION
REV#1 - INSTALL NEW PANEL (100 AMP); INSTALL NEW OUTLETS
I certify that I have read this application and state that the above
(24), RECESSED LIGHT (21) - ISSUED 9/13/18
information is correct. I agree to comply with all city and county ordinances
and state laws relating to building construction, and hereby authorize
Sq. Ft Floor Area:
Valuation: $35000.00
representatives of this city to enter upon the above mentioned property for
inspection purposes. (We) agree to save indemnify and keep harmless the
APN Number:
Occupancy Type:
City of Cupertino against liabilities, judgments, costs, and expenses which
36609 043
66
may accrue against said City in consequence of the granting of this permit.
Additionally, the applicant understands and will comply with all non -point
source regulations per the Cupertino Municipal Code, Section 9.18.
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PERMIT EXPIRES IF WORK IS NOT STARTED
Signature lT l Date 09/13/18
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of the
Issued by: Abby Ayende
following two reasons:
Date: 10/03/2017
t. I, 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
RE -ROOFS:
sale (Sec.7044, Business & Professions Code)
All roofs shall be inspected prior to any roofing material being installed. If a roof is
2. I, as owner of the property, am exclusively contracting with licensed
installed without first obtaining an inspection, I agree to remove all new materials for
contractors to construct the project (Sec.7044, Business & Professions Code).
inspection.
I hereby affirm under penalty of perjury one of the following three declarations:
t. I have and will maintain a Certificate of Consent to self -insure for Worker's
Signature of Applicant:
Compensation, as provided for by Section 3700 of the Labor Code, for the
Date: 09/13/18
performance of the work for which this permit is issued.
2. I have and will maintain Worker's Compensation Insurance, as provided for by
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
Section 3700 of the Labor Code, for the performance of the work for which this
permit is issued.
HAZARDOUS MATERIALS DISCLOSURE
3. I certify that in the performance of the work for which this permit is issued, I
I have read the hazardous materials requirements under Chapter 6.95 of the
shall not employ any person in any manner so as to become subject to the
California Health & Safety Code, Sections 25505, 25533, and 25534. I will
Worker's Compensation laws of California. If, after making this certificate of
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
exemption, I become subject to the Worker's Compensation provisions of the
Health & Safety Code, Section 25532(a) should 1 store or handle hazardous
Labor Code, I must forthwith comply with such provisions or this permit shall
material. Additionally, should I use equipment or devices which emit hazardous
be deemed revoked.
air contaminants as defined by the Bay Area Air Quality Management District I
will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and
APPLICANT CERTIFICATION
the Health & Safety Code, Sections 25505, 25533, and 25534.
1 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
Owner or authorized agent: ��
relating to building construction, and hereby authorize representatives of this city
Date: 1 /18
to enter upon the above mentioned property for inspection purposes. (We) agree
to save indemnify and keep harmless the City of Cupertino against liabilities,
CONSTRUCTION LENDING AGENCY
judgments, costs, and expenses which may accrue against said City in
I hereby affirm that there is a construction lending agency for the performance
consequence of the granting of this permit. Additionally, the applicant understands
of work's for which this permit is issued (Sec. 3097, Civ C.)
and will comply with all non -point source regulations per the Cupertino Municipal
Lender's Name
Code, Section 9.18.
Lender's Address
Signature lam" Date 09/13 18
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.