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15030141CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 20957 FAIRWOODS CT CONTRACTOR: THD AT-HOME PERMIT NO: 15030141 SERVICES, INC. OWNER'S NAME: ATLANTA, GA 30339-3913 PHONE NO: (510) 731-1004 LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL COMMERCIAL ❑ REPLACE 20 WINDOWS & 2 SLIDING GLASS DOORS C� License Class GI % Lie. # a JCS ©2 j (WILL 70D Z3 f MEET EGRESS & BE TERMPERED WHERE REQ'RD BY Contractor A-7 Date CODE) 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 Sq. Ft Floor Area: Valuation: $18892 e ance of the work for which this permit is issued. I e and will maintain Worker's Compensation Insurance, as provided for by tion 3700 of the Labor Code, f6r the performance of the work for which this p it is issued. APN Number: 35913113.00 Occupancy Type: APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED correct. I agree to comply with all city and county ordinances and state laws relating WITHIN 180 DAYS O + IT ISSUANCE OR to building construction, and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We) agree to save CALLED INSPECTION indemnify and keep harmless the City of Cupertino against liabilities, judgme costs, and expenses which may accrue against said City in conseque th granting of this permit. Additionally, the applicant underst d will Issue y: Date: 2_3 �S with all non-point source regulations per the Cupertino nicipal Code, Section 9 18. RE-ROOFS: Signature Date Z� 5 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-B DE ECLARATION Signature of Applicant: Date: I hereby affirm that I agept from the Contractor's License Law for one of the following two reaso s: ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER 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 HAZARDOUS MATERIALS DISCLOSURE 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 I hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the declarations: Health & Safety Code, Section 25532(a) should I store or handle hazardous I have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally, should I use equipment or devices which emit hazardous Compensation, as provided for by Section 3700 of the Labor Code, for the air contaminants as defined by the Bay Area Air Quality Management Distr' performance of the work for which this permit is issued. will maintain compliance with the Cupertino Municipal Code, Cha . 2 and I have and will maintain Worker's Compensation Insurance, as provided for by the 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. Owner or authorized agent: Date: 31-2- 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 CONSTRUCTI ING AGENCY become subject to the Worker's Compensation provisions of the Labor Code, I must I hereby affirm that there is a construction lending agency for the performance of forthwith comply with such provisions or this permit shall be deemed revoked. work's for which this permit is issued (Sec. 3097, Civ C.) Lender's Name APPLICANT CERTIFICATION Lender's Address 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, ARCHITECT'S DECLARATION costs, and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records. granting of this permit. Additionally, the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code, Section Licensed Professional 918. Signature Date