B-2017-0755 (2) CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO: B-2017-0755
10252 RICHWOOD DR CUPERTINO, CA 95014-3361 (369 08 025) CALIFORNIA HOME
BUILDERS & DESIGN
INC
SAN JOSE, CA 95112
OWNER'S NAME: DATE ISSUED: 08/15/2017
OWNER'S PHONE: PHONE NO: (
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class B Lic. #882158
Contractor CALIFORNIA HOME BUILDERS & DESIGN INC Date 08/31/2020 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:
1ST FLOOR REMODEL (1,358 S.F.); ADDITION OF (1,437 S.F.); (N)
I hereby affirm under penalty of perjury one of the following two declarations: COVERED PORCH (187 S.F.); REROOF; TEAR-OFF; INSTALL OSB;
and will maintain Worker's Compensation Insurance, as provided for by REV #2 - ADD DIRECT VENT FIREPLACE - ISSUED 10/19/2018
Section 3700 of the Labor Code, for the performance of the work for which this DEF #1 - TRUSS CALLS - ISSUED 10/23/2017
permit is issued. REV #1. - CHANGE DOOR AND WINDOW HEIGHT; ENLARGE
APPLICANT CERTIFICATION KITCHEN WINDOW; (3) SKYLIGHTS; (N) GUARD RAIL - ISSUED
I certify that I have read this application and state that the above 5/22/2018
information is correct. I agree to comply with all city and county ordinances
and state laws relating to building construction, and hereby authorize Sq. Ft Floor Area: 1437 Valuation: $300000.00
representatives of this city to enter upon the above mentioned property for
inspection purposes. (We) agree to save indemnify and keep harmless the APN Number: Occupancy Type:
City of Cupertino against liabilities, j dgments, costs, and expenses which 369 08 025 R-3 (Custom)
may accrue against said City in co equence of the granting of this permit.
Additionally, the applicant underst nds lr! will comply with all non-point
source regulations/per the Cupe ino nicipal Code, Section 9.18.
PERMIT EXPIRES IF WORD IS NOT STARTED
Signature Date 10/19/2018 WITHIN 180 DAYS OF PERMIT ISSUANCE OR
- 180 DAYS FROM LAST CALLED INSPECTION.
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of the Issued by: Kim Dunbar
following two reasons: Date: 08/15/2017
1. 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 RE-ROOFS:
sale (Sec.7044, Business & Professions Code) All roofs shall be inspected prior to any roofing material being installed. I:f a roof is
2. I, as owner of the property, am exclusively contracting with licensed installed without first obtaining an inspection, I agree to remove all new materials for
contractors to construct the project (Sec.7044, Business & Professions Code). inspection.
I hereby affirm under penalty of perjury one of the following three declarations:
1. I have and will maintain a Certificate of Consent to self-insure for Worker's Signature of Applicant:
Compensation, as provided for by Section 3700 of the Labor Code, for the Date: 10/19/2018
performance of the work for which this permit is issued.
2. I have and will maintain Worker's Compensation Insurance, as provided for by ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
Section 3700 of the Labor Code; for the performance of the work for which this
permit is issued. HAZARDOUS MATERIALS DISCLOSURE
3. I certify that in the performance of the work for which this permit is issued, I I have read the hazardous materials requirements under Chapter 6.95 of the
shall not employ any person in any manner so as to.become subject to the California Health & Safety Code, Sections 25505, 25533, and 25534. I will
Worker's Compensation laws of California. If, after making this certificate ofr maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
exemption, I become subject to the Worker's Compensation provisions of the Health & Safety Code, Section 25532(a) should I store or h dle.hazardous
Labor Code, i must forthwith comply with such provisions or this permit shall material. Additionally, should I use equipment or devices w ch emit hazardous
be deemed revoked, air contaminants as defined by the Bay Axea Air Quality na went District I
will maintain compliance with the Cup r no Municipal ode, hapten 9.12 and
APPLICANT CERTIFICATION the Health & Safety Code,
relating to building construction, and hereby authorize representatives of this city Owner authorized agent:
to enter upon the above mentioned property for inspection purposes. (We) agree Date: 10//19/2018 .
to save indemnify and keep harmless the City of Cupertino against liabilities, CONSTRUCTION LENDING AGENCY
judgments, costs, and expenses which may accrue against said City in I hereby affirm that there is a construction lending agency for the performance.
consequence of the granting of this permit. Additionally, the applicant 'understands of work's for which this permit is issued (Sec. 3097, Civ C.)
and will comply with all non-point source regulations per the Cupertino Municipal Lender's Name
Code, Section 9.18.
Lender's Address
Signature Date 10/19/2018 ARCHITECT'S DECLARATION
understand my plans shall be used as public records.