09090008CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 7818 ROBINDELL WAY
CONTRACTOR: TBD - TO BE DETERMINED
PERMIT NO: 09090008
OWNER'S
PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION
F r r
BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class Lic. #!
r
MECH RESIDENTIAL COMMERCIAL
Contractor Date
I hereby affirm that I am licensed under the provisions of Chapter 9
JOB DESCRIPTION: BATHROOM REMODEL, NON -
(commencing with Section 7000) of Division 3 of the Business & Professions
STRUCTUR.AL(36SQ),INCLUDE
Code and that my license is in full force and effect.
ELECTRIC/MECHNCLJPLUMBING
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.
Sq. Ft Floor Area:
Valuation: $8875
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.
APN Number: 36219032.00
Occupancy Type:
APPLICANT CERTIFICATION
I certify that 1 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
PERMIT EXPIRES IF WORK IS NOT STARTED
upon the above mentioned property for inspection purposes. (We) agree to save
indemnify and keep ham -Jess the City of Cupertino against liabilities, judgments,
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
costs, and expenses which may accrue against said City in consequence of the
DAYS FROM LAST CALLED INSPECTION.
granting180
of this permit. Additionally, the applicant understands and will comply
with all non -point source regulations per the Cupertino Municipal Code, Section
9.18.
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Issued bk Date:
Signature Date
❑ OWNER -BUILDER DECLARATION
RE -ROOFS:
All roofs shall be inspected prior to any roofing material being installed. If a roof is
hereby affirm that 1 am exempt from the Contractor's License Law for one of
installed without first obtaining an inspection, I agree to remove all new materials for
the following two reasons:
inspection.
I, as owner of the property, or my employees with wages as their sole compensation,
wil I do the work, and the structure is not intended or offered for sale (Sec.7044,
Signature of Applicant: Date:
Business & Professions Code)
I, 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:
HAZARDOUS MATERIALS DISCLOSURE
I have and will maintain a Certificate of Consent to self -insure for Worker's
I have read the hazardous materials requirements under Chapter 6.95 of the
Compensation, as provided for by Section 3700 of the Labor Code, for the
California Health & Safety Code, Sections 25505, 25533, and 25534. 1 will maintain
performance of the work for which this permit is issued.
compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health &
I have and will maintain Worker's Compensation hsurance, as provided for by
Safety Code, Section 25532(a) should I store or handle hazardous material.
Section 3700 of the Labor Code, for the performance of the work for which this
Additionally, should I use equipment or devices which emit hazardous air
permit is issued.
contaminants as defined by the Bay Area Air Quality Management District I will
.th
maintain compliance the Cupertino Municipal Code, Chapter 9.12 and the
I certify that in the performance of the work for which this permit is issued, I shall
AGENCY
APPLICANT CERTIFICATION
I hereby affirm that there is a construction lending agency for the performance of work's
I certify that I have read this application and state that the above information is
for which this permit is issued (Sec. 3097, Civ C.)
correct. I agree to comply with all city and county ordinances and state laws relating
Lender's Name
to building construction, and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We) agree to save
Lender's Address
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
ARCHITECT'S DECLARATION
with