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10020114 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 7552 HEATHERWOOD DR CONTRACTOR:TBD-TO BE DETERMINED PERMIT NO: 10020114 OWNER'S NAME: PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG F_ ELECT F PLUMB F License Class Lic.# MECH r- RESIDENTIAL F COMMERCIAL F Contractor Date I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:ADD 23SQ FT FAM RM ADDITION,NEW GABLE DORMER (commencing with Section 7000)of Division 3 of the Business&Professions OF Code and that my license is in full force and effect. EXISTING ROOF 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 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 Sq.Ft Floor Area: Valuation:$60000 permit is issued. APPLICANT CERTIFICATION APN Number:35928043.00 Occupancy Type: 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 to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We)agree to save PERMIT EXPIRES IF WORK IS NOT STARTED indemnify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City in consequence of the WITHIN 180 DAYS OF PERMIT ISSUANCE OR granting of this permit. Additionally,the applicant understands and will comply 180 DAYS FROM LAST CALLED INSPECTION. with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. Signature Date Issued by: --� Date: OWNER-BUILDER DECLARATION RE-ROOFS: I hereby affirm that I am exempt from the Contractor's License Law for one of All roofs shall be inspected prior to any roofing material being installed.If a roof is the following two reasons: installed without first obtaining an inspection,I agree to remove all new materials for I,as owner of the property,or my employees with wages as their sole compensation, inspection. will do the work,and the structure is not intended or offered for sale(Sec.7044, Business&Professions Code) Signature of Applicant: Date: 1,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044,Business&Professions Code). ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER I hereby affirm under penalty of perjury one of the following three declarations: I have and will maintain a Certificate of Consent to self-insure for Worker's HAZARDOUS MATERIALS DISCLOSURE Compensation,as provided for by Section 3700 of the Labor Code,for the I have read the hazardous materials requirements under Chapter 6.95 of the performance of the work for which this permit is issued. California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain I have and will maintain Worker's Compensation Insurance,as provided for by compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health& Section 3700 of the Labor Code,for the performance of the work for which this Safety Code,Section 25532(x)should I store or handle hazardous material. Additionally,should I use equipment or devices which emit hazardous air permit is issued. contaminants as defined b the Ba Area Air y y Quality Management District I will I certify that in the performance of the work for which this permit is issued,I shall maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the not employ any person in any manner so as to become subject to the Worker's Health&Safety Code,S ctions 25505,25533,and 25534. 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 Ow o a ze forthwith comply with such provisions or this permit shall be deemed revoked. Date: APPLICANT CERTIFICATION CONSTRUCTION LENDING AGENCY I certify that I have read this application and state that the above information is I hereby affirm that there is a construction lending agency for the performance of work's correct.I agree to comply with all city and county ordinances and state laws relating for which this permit is issued(Sec.3097,Civ C.) to building construction,and hereby authorize representatives of this city to enter Lender's Name upon the above mentioned property for inspection purposes.(We)agree to save i^demnify and keep harmless the City of Cupertino against liabilities,judgments, Lender's Address ,and expenses which may accrue against said City in consequence of the b.—iting of this permit.Addition ly, a applicant understands and will comply ARCHITECT'S DECLARATION with all non-point sour regu on er the Cupertino Municipal ode,Section 9.18. /, I understand my plans shall be used as public records. Signatur Date (/ Licensed Professional CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 7552 HEATHERWOOD DR CONTRACTOR: TBD - TO BE DETERMINED PERMIT NO: 10020114 OWNER'S NAME: PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATION Ir r f— BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class Lic. if T_ MECH RESIDENTIAL COMMERCIAL Contractor Date hereby affirm that 1 am licensed under the provisions of Chapter 9 JOB DESCRIPTION: ADD 23SQ FT FAM RM ADDITION, NEW GABLE DORMER (commencing with Section 7000) of Division 3 of the Business & Professions OF EXISTING ROOF 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 performance of the work for which this permit is issued. I have and will maintain Worker's Compensation Insurance, as provided for by Sq. Ft Floor Area: Valuation: $60000 Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. APPLICANT CERTIFICATION APN Number: 35928043.00 Occupancy Type: 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 to building construction, and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We) agree to save PERMIT EXPIRES IF WORK IS NOT STARTED indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs, and expenses which may accrue against said City in consequence of the WITHIN 180 DAYS OF PERMIT ISSUANCE OR granting of this permit. Additionally, the applicant understands and will comply 180 DAYS FROM LAST CALLED INSPECTION. with all non -point source regulations per the Cupertino Municipal Code, Section 9.18. Signature Date Issued by: ��^ Date: — OWNER -BUILDER DECLARATION RE -ROOFS: I hereby affirm that 1 am exempt from the Contractor's License Law for one of All roofs shall be inspected prior to any roofing material being installed. If a roof is the following two reasons: installed without first obtaining an inspection, 1 agree to remove all new materials for I, as owner of the property, or my employees with wages as their sole compensation, inspection. will do the work, and the structure is not intended or offered for sale (Sec.7044, Business & Professions Code) Signature of Applicant: Date: 1, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec.7044, Business & Professions Code). ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER I hereby affirm under penalty of perjury one of the following three declarations: I have and will maintain a Certificate of Consent to self -insure for Worker's HAZARDOUS MATERIALS DISCLOSURE Compensation, as provided for by Section 3700 of the Labor Code, for the 1 have read the hazardous materials requirements under Chapter 6.95 of the performance of the work for which this permit is issued. California Health & Safety Code, Sections 25505, 25533, and 25534. 1 will maintain I have and will maintain Worker's Compensation Insurance, as provided for by compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Section 3700 of the Labor Code, for the performance of the work for which this Safety Code, Section 25532(a) should 1 store or handle hazardous material. permit is issued. Additionally, should 1 use equipment or devices which emit hazardous air I certify that in the performance of the work for which this permit is issued, I shall contaminants as defined by the Bay Area Air Quality Management District 1 will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the not employ any person in any manner so as to become subject to the Worker's Health & Safety Code, S etions 25505, 25533, and 25534. 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 Ow 0 a ze forthwith comply with such provisions or this permit shall be deemed revoked. Date: 6 F/ APPLICANT CERTIFICATION CONSTRUCTION LENDING AGENCY I certify that I have read this application and state that the above information is I hereby affirm that there is a construction lending agency for the performance of work's correct. I agree to comply with all city and county ordinances and state laws relating for which this permit is issued (Sec. 3097, Civ C.) to building construction, and hereby authorize representatives of this city to enter Lender's Name upon the above mentioned property for inspection purposes. (We) agree to save indemnify and keep harmless the City of Cupertino against liabilities, judgments, Lender's Address costs, and expenses which may accrue against said City in consequence of the granting of this permit. Addition ly, the applicant understands and will comply with all non -point sour - rcgu ions er the Cupertino Municipal ode Section ARCHITECT'S DECLARATION 9.18. 1 understand my plans shall be used as public records. Signatur Date Licensed Professional