B-2019-1273 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2019-1273
10162 PARK CIRCLE E APT 2 CUPERTINO,CA 95014-1954(326 32 046)1 10162 PARK SOUTHWEST SAN
CIRCLE E APT 4 CUPERTINO,CA 95014-1954(326 32 046) JOSE RESTORATION
SERVICES LLC
SAN JOSE,CA 95153
OWNER'S NAME: DATE ISSUED:07/18/2019
OWNER'S PHONE: PHONE NO:(408)288-9977
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class B Lic.#937078
Contractor SOUTHWEST SAN JOSE RESTORATION SERVICES LLC Date X BLDG X ELECT _PLUMB
03/31/2021 _MECH X RESIDENTIAL_COMMERCIAL
I hereby affirm that I am licensed under the provisions of Chapter 9(commencing
with Section 7000)of Division 3 of the Business&Professions Code and that my JOB DESCRIPTION:
license is in full force and effect. REPAIR FIRE/SMOKE DAMAGE-REPAIR DAMAGE TO FRAMING
AND SHEATHING;REPAIR BRANCH CIRCUIT;REPLACE STUCCO-
I hereby affirm under penalty of perjury one of the following two declarations: (100 SF);REPLACE(2)WINDOWS LIKE FOR LIKE;REPAIR(2 SQ)
1. I have and will maintain a certificate of consent to self-insure for Worker's ROOFING.
Compensation,as provided for by Section 3700 of the Labor Code,for the
performance of the work for which this permit is issued. 10162 PARK CIRCLE E APT 4 CUPERTINO,CA 95014-1954(326 32 046
Section 3700 of the Labor Code,for the performance of the work for which this PARK CIRCLE,LLC
permit is issued. 10162 PARK CIRCLE E APT 2 CUPERTINO,CA 95014-1954(326 32 046
APPLICANT CERTIFICATION APT 2)
1 certify that I have read this application and state that the above PARK CIRCLE,LLC
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:$16000.00
representatives of this city to enter upon the above mentioned property for
inspection purposes. (We)agree to save indemnify and keep harmless the APN
City of Cupertino against liabilities,judgments,costs,and expenses which Number: Occupancy Type:
32632 046
may accrue against said City in consequence of the granting of this permit. 326
Additionally,the applicant understands and will comply with all non-point
source
Date 07/18/2019 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:Jasmine Archbold
following two reasons: Date:07/18/2019
1. 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:
1. 1 have and will maintain a Certificate of Consent to self-insure for Worker's Signature of Applicant:
Compen°sation,as provided for by Section 3700 of the Labor Code,for the Date:07/18/2019
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 I 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&
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 Date 07/18/2019 ARCHITECT'S DECLARATION