B-2017-0940 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2017-0940
10405 ANN ARBOR AVE CUPERTINO,CA 95014-1665(326 25 027) HOMESTEAD
CONSTRUCTION INC
CUPERTINO,CA 95014
OWNER'S NAME: DATE ISSUED:12/18/2017
OWNER'S PHONE: PHONE NO:(
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class 13 Lic.#681633
Contractor HOMESTEAD CONSTRUCTION INC Date 11/3O/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 fall farce and effect. JOB DESCRIPTION:
(N)ONE STORY SFD(3969 SF);ATTACHED GARAGE(458 SF);(I)
I hereby affirm under penalty of perjury one of the following two declarations: PORCH(60)
r. I have and will maintain a certificate of consent to self-insure for Worker's REV#1-Add roof at bay windows of family room and bed room 3;recessed
Compensation,as provided for by Section 3700 of the Labor Code,for the ceiling master bed room,bed room 4 and family room/nook area;Footing
performance of the work for which this permit is issued. for ceiling beam support;change trellis detail-ISSUED 6.2618
I have and will maintain Worker's Compensation Insurance,as provided£or by
Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued. Sq.Ft Flom-Ar—3969 Valuation:$730000.00
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: Oceupancy'fype:
and stale laws relating to building construction,and hereby authorize 32628 027 R-3(Custom)
representatives of this city to enter upon the above mentioned properly 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 er the Cupe ho Municipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION,
Signature Date 6.26 18 Issued by:SEAN HATCH
Data:12/18/2017
Eli-B LDER DECLARAT
I hereby affirm that I am exempt from the Contractor's License Lev t'ar no of the RE-ROOFS:
follmving two reasons: All roofs shall be inspected prior to any roofing material being installed.If a roof is
1, 1,as owner of the property,or my employees with wages as their sole installed without first obtaining an nspection,I agree to remove all new materials for
compensation,will do the work,and the suactme is not intended or offered for inspcctiom.
sale(See.7044,Business&Professions Code)
z. 1,as owner of the property,am exclusively contracting with licensed Signature ofApplicane
contractors to construct the project(Sec.7044,Business&Professions Code), Date:6.26.18
1 hereby affirm under penalty of perjury one or 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 far Worker's
Compensation,as provided for by Section 3700 of the Labor Code,for the
.performance of due work for which this permit is issued. HAZARDOUS MATERIALS DISCLOSURE
z. 1 have and will maintain Worker's Compensation Insurance,as provided for by I have read the hazardous materials requirements under Chapter 6.95 or the
Section 3700 of the Labor Code,for the performance of the work for which this California Health&Safety Cade,Sections 2.5505,25533,and 25534.1 will
it is issued, maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
permit Health&Safety Code,Section 25532(a)should 1 store n'handle hazardous
s. I certify that in they person in any of
work for which behiscome
permit is issued,1 mnterml.Additionally,slmuW I use equipment or devices which amit hazardous
shall not employ any person in cry manner so as to become subject to the r antaminants as donned by the Bay Area Air Quality Management District I
Worker's Compensation laws of California.If,after making this certificate of ,in maintain compliance with the Cupertino Municipal Code,Crispier 9.12 and
exemption,I become subject to the Worker's Compensation provisions of the the Health&Safety Code,Sec 25505,2 and 25534.
Labor Cade,I must forthwith comply with such provisions or this permit shall
be deemed revoked. Owner or authorized agent:
APPLICANT CERTIFICATION Date:6.2618
I certify that I have read this application and state that the above Information is CONSTRUC Io LE D GE CY
correct.I agree to comply with all city and county ordinances and state laws I hereby affirm that there Is a c ns action lending agency for the performance
relating to building construction,and hereby authorize representatives of this city of work's for which lits permit is'sued(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 Municipal ARCHITECT'S DECLARATION
Code,Section 9.18. 1 understand my plans shall be used as public records.
Licensed
Signature Date 6.26.18 professional