B-2018-0622 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2018-0622
1055 TUSCANY PL CUPERTINO,CA 95014-4325(359 29 034) OWNER/BUILDER
OWNER'S NAME: DATE ISSUED;07/17/2018
OWNER'S PHONE: PHONE NO:
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class Lic.#
Contractor OWNER/BUILDER Date X BLDG ELECT_PLUMB
I hereby affirm that I em licensed render the provisions ofChapter 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:
TO CLEAR CODE CASE-LEGALIZE LIVING ALTERATION INTO 2
I hereby affirm under penalty of perjury one of the following two declarations: (N)BEDROOMS(238 S.F.)
L I have and will maintain a certificate of cmzsent 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,
z. 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 - Sq.Ft Fluor Arco: Valuation:$5000.00
APPLICANT CERTIFICATION
I certify that I have read this application and slate that the above
information Is correct.I agree to comply with all city and county ordinances APN Number: Occu uou,y Type:
and state laws relating to building construction,and hereby authorize 359 29 034
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 PERMIT EXPIRES IF WORT{IS NOT STARTED
may accrue against said City in consequence of the granting of this permit WITHIN 180 DAYS OF PERMIT ISSUANCE OR
Additionally,the applicant understands and will comply with all non-point
source regulations per the Cupertino Municipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
Signature Date 07/17/2018 Issued by:Jasmine Archbold
Date:07/17/2018
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of the RE-ROOFS:
following two reasons: All roofs shall be inspected prior to any roofing material being installed.If a roof is
t. I,as owner of the property,or my employees with wages as their sole installed without first obtaining an inspection,1 agree to remove all new materials for
compensation,will do the work,and the Structure is not intended or offered for inspection.
as owner of property,am exclusively contracting with licensed Signature ofApplicaar.
contractors to construct the project(Sec.7044,Business&Professions Code). Date:07/17/2018
I hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
r. I have and will maintain a Certificate of Consent to self harre 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. HAZARDOUS MATERIALS DISCLOSURE
z. I have and will maintain Worker's Compensation Insurance,as provided fur by I have read the hazardous materials requirements trader Chapter 6.95 of the
Section 3700 of the Labor Code,for the performance of the work For which this California Health&Safety Code,Sardinia 25505,25533,..,it 25534.I will
permit is issued. urn aintain compliance with the Cupertino Municipal Code,Chapter 9,12 and the
s. 1 certify that in the performance of the work for which this permit is issued,1 Health&Safely Code,Section 25532(x)should I store m•handle hazardous
shall not employ material.Addifimodly,should 1 use equipment or devices which emit hazardous
p y any person in any manner so as to become subject to the air contaminants as defined by the Bay Area Air Quality Management District I
Worker's Compensation laws of California.If,after making this certificate of will maintain compliance with the Cupertino Municipal Code,Cliapter9.12 and
emption,l become subject to the Worker's Compensation provisions of the the Iiealth&Safety Code,Sections 25505,25533,and 25534.
Labor Cade,l must forthwith comply with such provisions or this permit shall
be dccmcd revoked. Owner or authorized agent:
correct.I agree to comply with all city and county ordinances and state laws I hereby affirm that there is a construction lending agency for the performance
relating to building construction,and hereby authorize representatives of this city of work's for which this permit is issued(Sec,3097,Civ C.)
to enter upon the above mentioned property for inspection purposes. (We)agree Lender's Name
to save indemnify and keep harmless the City of Cupertino against liabilities,
judgments,costs,and expenses which may accrue against said City In Lender's Address
consequence of the granting of this permit.Additionally,the applicant understands
and will comply with all non-point source regulations per the Cupertino MunicipalARCHITECT'S DECLARATION
Code,Section
07/17/2018 Professional