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B-2019-0129 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2419-0129 21088 TULITA CT Cupertino,CA 95014(326 28 071)121090 TULITA CT CUPERTINO, BUILD BY TITAN INC CA 95014-1639(326 28 07 1) SAN JOSE,CA 95112 OWNER'S NAME: DATE ISSUED:05/22/2019 OWNER'S PHONE: PHONE NO:(408)338-7788 LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: License Class B.C Lic.#948867 Contractor BUILD BY TITAN INC Date 06/30/2020 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: CONSTURCT(N)2-STORY SINGLE FAMILY DWELLING-(3915 SF); I hereby affirm under penalty of perjury one of the following two declarations: CONSTRUCT(N)ATTACHED SECOND DWELLING UNIT-(641 SF); 1. I have and will maintain a certificate of consent to self-insure for Worker's (N)2-CAR GARAGE-(469 SF);(N)PORCH-(798 SF) Compensation,as provided for by Section 3700 of the Labor Code,for the perfonnance 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. Sq.Ft Floor Area:4384 Valuation:$910000.00 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 32628071 R-3(Custom),R-3(Custoin),U(Private Gar/Ag Bldg),U representatives of this city to enter upon the above mentioned property for (Private Gar/Ag Bldg) inspection purposes. (We)agree to save indemnify and keep harmless the City of Cupertino against liabilities,judgments,costs,and expenses which may accrue against said City in consequence of the granting of this permit. PERMIT EXPIRES IF WORK IS NOT STARTED Additionally,the applicant understands and will comply with all non-point WITHIN 180 DAYS OF PERMIT ISSUANCE OR source regulations Section 9.18. -� 180 DAYS FROM LAST CALLED INSPECTION. Signature '"` Date 05/22/2019 Issued by:Jasmine Archbold OWNER-BUILDER DECLARATION Date:05/22/2019 I hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: RE-ROOFS: 1. I,as owner of the property,or my employees with wages as their sole All roofs shall be inspected prior to any roofing material being installed.If a roof is compensation,will do the work,and the structure is not intended or offered for installed without first obtaining an inspection,I agree to remove all new materials for sale(Sec.7044,Business&Professions Code) inspection. 2. I,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044,Business&Professions Code). Signature of Applicant: Date:05/22/2019 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. 2. I have and will maintain Worker's Compensation Insurance,as provided for by HAZARDOUS MATERIALS DISCLOSURE Section 3700 of the Labor Code,for the performance of the work for which this I have read the hazardous materials requirements under Chapter 6.95 of the permit is issued. California Health&Safety Code,Sections 25505,25533,and 25534. I will 3. I certify that in the performance of the work for which this permit is issued'I maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the 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 be deemed revoked. APPLICANT CERTIFICATION Owner or authorized agent: I certify that I have read this application and state that the above information is Date:05/22/2019 correct.I agree to comply with all city and county ordinances and state laws CONSTRUCTION LENDING AGENCY relating to building construction,and hereby authorize representatives of this city I hereby affirm that there is a construction lending agency for the performance to enter upon the above mentioned property for inspection purposes. (We)agree of work's for which this permit is issued(Sec.3097,Civ C.) to save indemnify and keep harmless the City of Cupertino against liabilities, Lender's Name judgments,costs,and expenses which may accrue against said City in consequence of the granting of this permit. Additionally,the applicant understands Lender's Address and will comply with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. ARCHITECT'S DECLARATION I understand my plans shall be used as public records. Signature Date 05/22/2019 Licensed Professional