B-2017-0161 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2017-0161 .
11801 DOROTHY ANNE WAY CUPERTINO,CA 95014-5137(366.09 043) HOMEOWNER
BUILDER
OWNER'S NAME: DATE ISSUED: 10/03/2017
OWNER'S PHONE: PHONE NO:
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class Lic.#
Contractor HOMEOWNER BUILDER Date X BLDG _ELECT _PLUMB
MECH X RESIDENTIAL_COMMERCIAL
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. JOB DESCRIPTION:
TO CLEAR CODE ENFORCEMENT: RANCH OFFICE-REMOVE
I hereby affirm under penalty of perjury one of the following two declarations: KITCHEN AND CONVERT BACK TO AN ACCESSORY STRUCTURE
1. I have and will maintain a certificate of consent to self-insure for Worker's (1319 S.F.);LEGALIZE ADDITION(640 S.F.). (*NOTE:SHALL NOT
Compensation,as provided for by Section 3700 of the Labor Code,for the BE USED AS A SEPARATE DWELLING UNIT*)
performance of the work 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:640 Valuation:$12000.00
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: Occupancy Type:
and state laws relating to building construction,and hereby authorize 366 09 043 A-1,R-3(Custom),R-3(Custom),A-1,A-1,A-1,A-1,A-1,A-
representatives of this city to enter upon the above mentioned property for 1,A-1,A-1,A-I
inspection purposes. (We)agree to save indemnify and keep harmless the
City of Cupertino against liabilities,judgments,costs,and expenses which
may accrue against said City in consequence of the granting of this permit. PERMIT EXPIRES IF WORK IS NOT STARTED
Additionally,the applicant understands and will comply with all non-point WITHIN 180 DAYS OF PERMIT ISSUANCE OR
source regulations per the Cupertino Municipal Code,Section 9.18.
180 DAYS FROM LAST CALLED INSPECTION.
Signature Date 10/3/2017
Issued by:Abby Avende
OWNER-BUILDER DECLARATION Date: 1.0/03/2017
, I hereby affirm that I am exempt from the Contractor's License Law for one of the
following two reasons: RE-ROOFS:
1. I,as owner of the property,or my employees with wages as their sole All roofs shall be inspected prior to any roofing material being installed.If a roof is
compensation,will do the work,and the structure is not intended or offered for installed without first obtaining an inspection,I agree to remove all new materials for
sale(Sec.7044,Business&Professions Code) inspection.
I,as owner of the property,am exclusively contracting with licensed'
contractors to construct the project(Sec.7044,Business&Professions Code). Signature of Applicant:
Date: 10/3/2017
I hereby affirm under penalty of perjury one of the following three declarations:
i. I have and will maintain a Certificate of Consent to self-insure for Worker's
ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
Compensation,as provided for by Section 3700 of the Labor Code,for the
/ erformance
of the work for which this permit is issued.
have and will maintain Worker's Compensation Insurance,as provided for by HAZARDOUS MATERIALS DISCLOSURE
Section 3700 of the Labor Code,for the performance of the work for which this I have read the hazardous materials requirements under Chapter 6.95 of the
permit is issued. California Health&Safety Code,Sections 25505,25533,and 25534. I will
s. I certify that in the performance of the work for which this permit is issued,I maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
shall not employ any person in any manner so as to become subject to the Health&Safety Code,Section 25532(a)should I store or handle hazardous
'E material. Additionally,should I use equipment or devices which emit hazardous
Worker's Compensation laws of California. If,after making this certificate of air contaminants as defined by the Bay Area Air Quality Management District I
1. exemption,I become subject to the Worker's Compensation provisions of the will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and
Labor Code,I must forthwith comply with such provisions or this permit shall the Health&Safety Code,Sections 25505,25533,and 25534.
be deemed revoked.
APPLICANT CERTIFICATION , u ner or authorized agent:
I certify that I have read this application and state that the above information is • Date:10/3/2017
correct.I agree to comply with all city and county ordinances and state laws CONSTRUCTION LENDING AGENCY
relating to building construction,and hereby authorize representatives of this city I hereby affirm that there is a construction lending agency for the performance
to enter upon the above mentioned property for inspection purposes. (We)agree of work's for which this permit is issued(Sec.3097,Civ C.)
to save indemnify and keep harmless the City of Cupertino against liabilities, Lender's Name
judgments,costs,and expenses which may accrue against said City in
consequence of the granting of this permit. Additionally,the applicant understands Lender's Address
and will comply with all non-point source regulations per the Cupertino Municipal
Code,Section 9.18. ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
r
j gnature -� � Date 10/3/2017 Licensed
Professional