B-2018-1354 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMITNO:B-2018-1354
10078 RIDGEWAY DR CUPERTINO,CA 95014-2685(342 41 019) OWNER/BUILDER
OWNER'S NAME: DATE ISSUED:08/10/2018
OWNER'S PHONE: PHONE Na
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class Lic.#
Contractor OWNER/BUILDER Date X BLDG ELECT—PLUMB
I hereby afib•m that I am licensed render the previsions of Chapter 9(commencing MECH X RESIDENTIAL COMMERCIAL
with Section 7000)of Division 3 of the Business&Professions Code and that my
license is in full form and effect. JOB DESCRIPTION:
BATHROOM REMODEL(95 SF)
1 hereby affirm under penalty of perjury one of the following two declarations:
t. I have and will maintain a certificate of consent to self-insure for Workers
Compensation,as provided for by Section 3700 of the Labor Cade,for the
performance of the work for which this permit is issued.
i. 1 have and will maintain Worker's Compensation Insurance,as provided for by
Section 3700 of the Labor Code,for the perfunni nce of the work for which this
permit is issued. Sq.Ft Floor Area: Valuation:$15000.00
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 APN Number: Occupancy'pylae:
and state laws relating to building construction,and hereby authorize 342 41 019
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 WORK 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 8-10-2018 Issued by:Kim Dunbar
Date:08/10/2018
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of the RE-ROOFS:
foil o reasons: All roofs shall be inspected prior to any roofing nintedul being instalicd.I£a roof is
as owner of the property,or my employees with wages as their sole installed without first obtaining an inspection,I agree to remove all new materials for
compensation,will do the work,and the structure is not Intended in offered for nspectian.
sale(Sec.7044,Business&Professions Code)
z. 1,as owner of the property,am exclusively contracting with licensed Signature of ApplicanC
contractors to constnet the project(Sec.7044,Business&Professieus Code). Date:8-10-2018
I hereby affirm under penalty of perjury one of the following three declarations: ALL 1200E COVERINGS TO BE CLASS"A"OR BETTER
r. 1 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 oftle,work for which this permit is issued. HAZARDOUS MATERIALS DISCLOSURE
z. f have and will maintain Worker's Compensation Insurance,as provided for by I have read the hnrm•dons materials requirements under Chapter 6.95 of the
Section 3700 of the Labor Code,for the performance of the work for which this California Henith&Safety Code,Sections 25505,25533,and 25534•I will
permit is issued. ombitnhr compliance with the Cupertino Municipal Code,Chapter 9.12 and the
3. I certify that in the performance of the work for which this permit is issued,I Health&Safety Code,Section 25532(a)should I store or handle hazardous
shall not employ any person iu any nuumer so as to become subject to the material.Additionally,should I use equipment or devices which emit hazardous
air contaminants as defined by the Bay Area Air Quality Management District I
Worker's Compensation laws of California.If,ager making this certificate of will maintain cemplhmeo with the Cupertino Municipal Code,Chapter 9.12 and
exemption,I become subject to the Worker's Compensation provisions of the the Henith&
_
APYL[CANT CERTIFICATION Date:8-10-2018
I certify that I have read this applicallon and state that the above information is CONSTRUCTIO 'NDING AGENCY
correct.I agree to comply with all city and county ordinances and state laws I hereby affirm that there is a constr Ion 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 indemnifyand 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 M non-point source regulations per the Cupertino MunicipalARCHITECT'S DECLARATION
Code,Section 9 I understand my plans shall be used as public records.
Licensed
Signature ale 8-10-2018 professional