B-2019-0367 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2019-0367
10140 ORANGE AVE CUPERTINO,CA 95014-2839(357 17 102) NN DESIGN AND
BUILD
SAN JOSE,CA 95136
OWNER'S NAME: DATE ISSUED:06/27/2019
OWNER'S PHONE: PHONE NO:(408)460-8169
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class B Lic.#1037069
Contractor NN DESIGN AND BUILD Date 03/31/2020 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:
KITCHEN REMODEL(100 SF);REMODEL(3)BATHROOMS(180 SF);
I hereby affirm under penalty of perjury one of the following two declarations: (N)COVERED PORCH(82 SF); REMOVE ENTIRE PITCHED ROOF
1. I have and will maintain a certificate of consent to self-insure for Worker's STRUCTURE AND REPLACE WITH FLAT ROOF STRUCTURE(1294
Compensation,as provided for by Section 3700 of the Labor Code,for the SF);REPLACE WOOD SIDING WITH STUCCO(1650 SF);RE-ROOF-
performance of the work for which this permit is issued. TEAR-OFF-INSTALL 3/8"CDX-INSTALL ASPHALT SHINGLES(13
I have and will maintain Worker's Compensation Insurance,as provided for by SQ);ADD(1)WINDOW TO UPSTAIRS BATHROOM;ENLARGE(1)
? Section 3700 of the Labor Code for theerformance of the work f
p o or which this WINDOW IN BEDROOM#2 AND THE GREAT ROOM;REPLACE
permit is issued. WINDOWS(11)AND DOORS(3);(N)SKYLIGHT 2ND FLOOR
APPLICANT CERTIFICATION BATHROOM;REMOVE(E)STAIRCASE AND REPLACE WITH(N)
certify that I have read this application and state that the above FREE STANDING METAL STAIRCASE;INSTALL(17)(N)LIGHTS
information is correct. I agree to comply with all city and county ordinances OUTSIDE BATHROOMS AND KITCHENS.
and state laws relating to building construction,and hereby authorize
representatives of this city to enter upon the above mentioned property for Sq.Ft Floor Area: Valuation:$200000.00
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 co sequence of the granting of this permit. APN Number: Occupancy Type:
Additionally,the applicant underp4nds and will comply with all non-point 357 17 102
source
OWNER-B ILDER DECLARATION 180 DAYS FROM LAST CALLED INSPECTION.
I hereby affirm that I am exempt from the Contractor's License Law for one of the
following two reasons: Issued by:Kim Dunbar
1. I,as owner of the property,or my employees with wages as their sole Date:06/27/2019
compensation,will do the work,and the structure is not intended or offered for
sale(Sec.7044,Business&Professions Code) RE-ROOFS:
2. I,as owner of the property,am exclusively contracting with licensed All roofs shall be inspected prior to any roofing material being installed.If a roof is
contractors to construct the project(Sec.7044,Business&Professions Code). installed without first obtaining an inspection,I agree to remove all new materials for
I hereby affirm under penalty of perjury one of the following three declarations:
inspection.
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 Signature of Applicant:
performance of the work for which this permit is issued. Date:6-27-2019
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 ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
permit is issued.
3. I certify that in the performance of the work for which this permit is issued,I HAZARDOUS MATERIALS DISCLOSURE
shall not employ any person in any manner so as to become subject to the I have read the hazardous materials requirements under Chapter 6.95 of the
Worker's Compensation laws of California. If,after making this certificate of California Health&Safety Code,Sections 25505,25533,and 25534. I will
exemption,I become subject to the Worker's Compensation provisions of the maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
Labor Code,I must forthwith comply with such provisions or this permit shall Health&Safety Code,Section 25532(a)should I store or handle hazardous
be deemed revoked. material. Additionally,should I use equipment or devices which emit hazardous
air contaminants as defined by the Bay Area Air Quality Management District I
APPLICANT CERTIFICATION will maintain compliance with the Cupertino Municip ode,Chapter 9.12 and
certify that I have read this application and state that the above information is the Health&Safety
to enter upon the above mentioned property for inspection purposes. (We)agree 9
to save indemnify and keep harmless the City of Cupertino against liabilities, Date:6-27-2019
judgments,costs,and expenses which may accrue against said City in CONSTRULTION LENDING AGENCY
consequence of the granting of this permit. Additionally,the applicant understands I hereby affirm that there is a construction lending agency for the performance
and will comply with all non-point source regulations per the Cupertino Municipal of work's for which this permit is issued(Sec.3097,Civ C.)
Code,Section 9.18. Lender's Name
Lender's Address
Signature Date 6-27-2019
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.