B-2018-1253 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERM IT NO:B-2018-1253
10141 EMPIRE AVE CUPERTINO,CA 95014-1204(326 24 009) (Evans 18,LLC)
2542 S Bascom Ave 130
Campbell,CA 95014-
4816
OWNER'S NAME;( DATE ISSUED:07/30/2018
OWNER'S PHONE: PHONE NO:Noac
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO;
License Class Lis.# BLDG AY ELECT X PLUMB
Contractor!Evans 18 LLC 1 Date x
-� MECH X RESIDENTIAL COMMERCIAL
1 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. JOB DESCRIPTION;
BATHROOM REMODEL(2)(35 SF);KITCHEN REMODEL(80 SF);
I hereby affirm under penalty of perjury one of the following two declarations: NEW LIGHTING(I4);NEW LAUNDRY RM OUTLET(1);INSTALL
L I have and will maintain a certificate of consent to self-insure for Worker's NEW TANKLESS WATER HEATER
Compensatiou,as provided for by Section 3700 Of the Labor Code,for the
performmce of the work for which this permit is issued.
,3700 of the Labor Code,for the performance of the work for which this
permit is issued. Sq.Ft Floor Area: Valentine$83000.OD
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: Occupancy Type:
and state laws relating to building construction,and hereby authorize 326 24 009
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 Municipal Code,section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
Signature Date 07/30/2018 Issued by:Jasmine Archbold
Date:07/30/2018
LARATION
I hereby affirm that I am exempt from the Contractor's Licanso Law for One of the RE-ROOFS:
following two reasons: All roofs shall be inspected prior to any rooting material being installed.Us too£is
r. 1,as Owner ofthe property,or my employees with wages as their sole installed without firstobtaming an inspection,I agree to remove all new materials for
compensation,will do the work,and the structme,is not intended or offered for inspection.
sale(Sec.7044,Business&Professions Code)
z. 1,as owner of the property,am exclusively contracting with licensed Signature of Applicant,
contractors to construct the project(See.7044,Business&Professions Code), Date:07/30/2018
1 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.sel£-insure for Worker's
Compensation,as provided for by Section 3700 of the Labor Code,for the
performance attire 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&SOI'ety Code,Sections 25505,25533,and 25534.I will
permit is issued. maintain compliance with the Cupertino Municipal Coda,Chapter 9.12 and the
s. I certify that in the performance of the work for which this permit is issued,l Health&Safety Code,Section 25532(a)should 1 store or handle hazardous
shall not employ any person in any manner so as to become subject to the material.Additionally,should 1 use equipment or devices which emit hazardous
air contamtmnts as defined by the Buy At ca 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,Chapter 9.12 and
exemption,I become subject to the Worker's Compensation provisions o£the the Health&Safety and 25534.
Labor Code,I must forthwith comply with such provisions or this permit shall
be deemed revoked, Owner or authorized agent:
APPLICANT CERTIFICATION Data:07/30/2018
I certify that I have read this application and state that the above information is CONSTRUC VON LENDING;AGENCY
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, Lender's Address
judgments,costs,and expenses which may accrue against said City in
consequence of the granting of this permit.Additionally,the applicant understands
and will comply with all non-point source regulations per the Cupertino Municipal ARCHIT'ECT'S DECLARATION
Code,Section 9.18. 1 understand my plans shall be used as public records.
Signature Date 07/30/2018 Licensed
Professional