B-2016-3053CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS:
CONTRACTOR:
PERMIT NO: B-2016-3053
873 FERNGROVE DR CUPERTINO, CA 95014-4636 (375 39 049)
COMPLETE
CONSTRUCTION
EXPERTS INC
SAN JOSE, CA 95129
OWNER'S NAME:
DATE ISSUED: 11/07/2016
OWNER'S PHONE:
PHONE NO: (408) 650-2432
LICENSED CONTRACTOR'S DECLARATION
WIELDING PERMIT INFO:
License Class @ Lic. #1009320
Contractor COMPLETE CONSTRUCTION EXPERTS INCDate 12/31/2017
X BLDG X 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 (100 S.F.); HALLWAY AND MASTER -
I hereby affirm under penalty of perjury one of the following two declarations:
BATHROOM REMODEL (100 S.F!); REPLACE PANEL (200 AMP);
1. I have and will maintain a certificate of consent to self -insure for Worker's
SAME LOCATION; REWIRE ONE STORY HOME (1200 S.F.)
Compensation, as provided for by Section 3700 of the Labor Code, for the
performance of the work for which this permit is issued.
ave and will maintain Worker's Compensation Insurance, as provided for by
ection 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
certify that I have read this application and state that the above
APN Number:
;
Occupancy Type:
information is correct. I agree to comply with all city and county ordinances
and state laws relating to building construction, and hereby authorize
375 39 049
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
Code, Section 9.18.
180 DAYS FROM LAST CALLED INSPECTION.
Signature Date 11/7/2016
Issued by. Abby A e� nde
Date: 11/07/2016
OWNER-BLT17 DER DE .AR TION
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
1. I, 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 or offered for
inspection..
sale (Sec.7044, Business & Professions Code)
2. I, as owner of the property, am exclusively contracting with licensed
Signature ofApplicant:
contractors to construct the project (Sec.7044, Business & Professions Code).
Date: I IM2016:
I hereby affirm under penalty of perjury one of the following three declarations;
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
1. 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 of the work for which this permit is issued.
HAZARDOUS MATERIALS DISCLOSURE
2. 1 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. 1 will
permit is issued.
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
s. 1 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 in any manner 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, after making this certificate of
will maintain compliance with the
deemed revoked.
Owner or authorized agent:
APPLICANT CERTIFICATION
Date: 11/7/2016
certify that I have read this application and state that the above information is
CONS CTIONLE G AGENCY
correct. I agree to comply with all city and county ordinances and state laws
1 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. Additionally, the applicant understands
and will comply with all non -point source regulations per the Cupertino Municipal
ARCHITECTS DECLARATION
Code, Section 9.18.
1 understand my plans shall be used as public records.
Signature Date 11R/2016
-
Licensed
Professional