09010037CITY OF CUPERTINO BUILDING PERMIT I
I BUILDING ADDRESS: 21881 DELORES AVE I CONTRACTOR: TBD - TO BE DETERMINED I PERMIT NO: 09010037 1
OWNER'S. NAME:
1 , 1 PHONE NO: I
❑ LICENSED CONTRACTOR'S DECLARATION
License Class Lic. #
Contractor
Date
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:
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.
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
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
! / OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons:
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)
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:
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.
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.
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 shall be deemed revoked.
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 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 the Cupertino Municipal Code, Section
9.18.
Licensed Professiona
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 21881 DOLORES AVE
CONTRACTOR: TRACY HSU
PERMIT NO: 09010037
OWNER'S NAME:
CUPERTINO, CA 95014
PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION
JOB DESCRIPTION: RESIDENTIAL ❑ COMMERCIAL ❑
NEW 2 STORY SFDWL.3,884' W/ATTACHED GARAGE 473'
License Class Lie. #
LOT 1
04/27/2010-REVISION # I,REVISE MASTER BATHROOM LAYOUT FOR PRIVACY
Contractor Date
PROTECTION. REVISION ISSUED 6/1/10.
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:
Sq. Ft Floor Area:
Valuation: $810000
t. 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
APN Number: 35714080.00
Occupancy Type:
Section 3700 of the Labor Code, for the performance of the work for which this
permit is issued.
APPLICANT CERTIFICATION
PERMIT EXPIRES IF WORK IS NOT STARTED
I certify that I have read this application and state that the above information is
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
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
180 DAYS FROM LAST CALLED INSPECTION.
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
Issued by: Date:
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
RE -ROOFS:
All roofs shall be inspected prior to any roofing material being installed. If a roof is
installed without first obtaining an inspection, I agree to remove all new materials for
inspection.
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of
Signature of Applicant: Date:
the following two reasons:
t. 1, as owner of the property, or my employees with wages as their sole
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
compensation, will do the work, and the structure is not intended or offered for
sale (Sec.7044, Business & Professions Code)
HAZARDOUS MATERIALS DISCLOSURE
2. I, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec.7044, Business & Professions Code).,/
I have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain
I hereby affirm under penalty of perjury one of the following three declarations:
compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health &
t. I have and will maintain a Certificate of Consent to self -insure for Worker's
Safety Code, Section 25532(a) should I store or handle hazardous material.
Compensation, as provided for by Section 3700 of the Labor Code, for the
Additionally, should I use equipment or devices which emit hazardous air
contaminants as defined by the Bay Area Air Quality Management District I will
performance of the work for which this permit is issued.
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
2. I have and will maintain Worker's Compensation Insurance, as provided for by
Health & Safety Code, Sections 25505, 25533, and 25534.
Section 3700 of the Labor Code, for the performance of the work for which this
permit is issued.
Ow r o authoriod ag 6
GENCY
become subject to the Worker's Compensation provisions of the Labor Code, I
I hereby affirm that there is a construction lending agency for the performance of work's
must forthwith comply with such provisions or this permit shall be deemed--6,
for which this permit is issued (Sec. 3097, Civ C.)
revoked.
Lender's Name
Lender's Address
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 and state laws relating
ARCHITECT'S DECLARATION
to building construction, and hereby authorize representatives of this city to enter
I understand my plans shall be used as public records.
upon the above mentioned property for inspection purposes. (We) agree to save
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
Licensed Professional
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 -