B-2018-1293 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2018-1293
22013 BAXLEY CT CUPERTINO,CA 95014-4744(356 06 021) BAY CONSTRUCTION
COMPANY
UNION CITY,CA 94587
OWNER'S NAME:(Fora Seasons Homes,LLC) DATE ISSUED:08/17/2018
OWNER'S PHONE: PHONE NO:(
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class 5 Lie.#865768
Contractor BAY CONSTRUCTION COMPANY Date 10/31/2019 X BLDG_ELECT_PLUMB
I hereby affirm that I am licensed under the provisions 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 force and effect JOB DESCRIPTION:
KITCHEN REMODEL(130 SF)
I hereby affirm under penalty of perjury one of the following two declarations:
n. 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 wo&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 Sq.Ft Floor Area: Valuation:$20000.00
APPLICANT CERTIFICATION
I certify that I have read this application and stale that the above
Information Is correct.I agree to comply with all city and county ordinances APN Number: Occupancy Type:
and state laws relating to building construction,and hereby authorize 356 06 021
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 Cu ertlno Muni[pal Sectlon 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
/01
Signature / Date 8 17.16 Issued by:SEAN HATCH
Date:08/17/2018
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
r. I,as owner of the property,or my employees with wages as their solo installed without fast obtaining an inspection,I agree to remove all new materials for
compensation,will do the work,and the structure is not intended or offered for inspection.
sale(Sce.7044,Business&Professions Code)
2. I,as owner of the property,am exclusively contracting with licensed Signature of Applicant:
contractors to construct the project(Sec.7044,Business&Professions Code). Date:8.17.16
I hereby affirm under penally 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-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. HAZARDOUS MATERIALS DISCLOSURE
2. I have and will maintain Worker's Compensation Insurance,as provided for by I have read the hazardous materials requirements under Chapter 6.95 of the
Section 3700 of the labor Code,for the performance of the work for which this California Health&Safety Code,Sections 25505,25533,and 25534.I will
permit is issued. maintain compliance with the Cupertino Municipal Cade,Chapter 9.12 and the
s. I certify that in the performance of the work for which this permit is issued,I Health&Safety Code,Section 25532(x)should I store or handle hazardous
shall not employ any person in any manner so as to become subject to the material.Additionally,should I use equipment or devices which emit hazardous
Worker's Compensation laws of California.If,after making this cerhficatc of air contaminants as defined by the Bay Area Air Quality Management District I
P g will maintain compliance with the Cupertino Municipal C de,Ch
caChapter 9.12 and
exemption,I beme subject to the Worker's Compensation provisions of the the Health&Safety Code,Sections 25505,25 ,
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.Addltlonally,the applicant understands
and will comply with all non-point source regulations per the Cupertino Municipal ARCHITECT'S DECLARATION
Code,Section 9.18. 1 understand my plans shall be used es public records.
Signature Date 8.17.16 Licensed
Professional