BLD-2020-0537PERMIT
CITY OF CUPERTINO BUILDING
BUILDING ADDRESS:22284 DE ANZA CIR N, Cupertino, CA 95014-3951
CONTRACTOR:
WARNER
CUSTOM
HOMES INC
PERMIT NO:BLI-2020-0537
OWNER'S NAME:BLAINE RICHARD A AND SHARON TRUSTEE
DATE ISSUED:
OWNER'S PHONE:
PHONE NO:5104274260
LICENSED CONTRACTOR'S DECLARATION
BUILDING PERMIT INFO:Residential Alteration
_ BLDG ELECT PLUMB
- MECH _ 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 license is in full force and
effect.
I hereby affirm under penalty of perjury one of the following two declarations:
17 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.
T 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.
APPLICANT CERTIFICATION
Sq. Ft Floor Area:
_
Valuation: $ 4000
APN Number:
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 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. Additionally,
the applicant understands and will comply with all non -point source regulations per the Cupertino
Municipal Code, Section 9.18.
Signature Date
—
PERMIT
WITHIN
180 DAYS
Issued by:
Date:
-
EXPIRES IF WORK IS NOT STARTED
180 DAYS OF PERMIT ISSUANCE OR
FROM LAST CALLED INSPECTION.
OWNER - BUILDER DECLARATION
All roofs shall be
installed without first
Signature of Applicant:
Date:
ALL ROOF
RE -ROOFS:
-
I hereby affirm that I am exempt from the Contractor's License Law for one of the following two
reasons:
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 sale (Sec.7044,
Business & Professions Code)
2. I, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec.7044, Business & Professions Code).
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
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 Section
3700 of the Labor Code, for the performance of the work for which this permit is
issued.
3. I certify that in the performance of the work for which this permit is issued, I shall not
employ any person in any manner so as to become subject to the Worker's
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
forthwith comply with such provisions or this permit shallbe deemed revoked.
APPLICANT CERTIFICATION
inspected prior to any roofing material being installed. If a roof is
obtaining an inspection, I agree to remove all new materials for
inspection..
COVERINGS TO BE CLASS "A" OR BETTER
I have read the
California Health &
compliance with
Safety Code, Section
Additionally,
contaminants as defined
maintain compliance
Health
Owner or authorized
Date:
I hereby affirm that there
of work's for which this
Lender's Name
Lender's Address
I understand my plans
Licensed
Professional
_
HAZARDOUS MATERIALS DISCLOSURE
hazardous materials requirements under Chapter 6.95 of the
Safety Code, Sections 25505, 25533, and 25534. I will maintain
the Cupertino Municipal Code, Chapter 9.12 and the Health &
25532(a) should I store or handle hazardous material.
should I use equipment or devices which emit hazardous air
by the Bay Area Air Quality Management District. I will
with the Cupertino Municipal Code, Chapter 9.12 and the
& Safety Code, Sections 25505, 25533, and 25534.
agent:
CONSTRUCTION LENDING AGENCY
is a construction lending agency for the performance
permit is issued (Sec. 3097, Civ C.)
ARCHITECT'S DECLARATION
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 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. Additionally,
the applicant understands and will comply with all non -point source regulations per the Cupertino
Municipal Code, Section 9.18.
shall be used as public records.