12010106 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 18655 LOREE AVE CONTRACTOR:DRAIN DOCTOR PERMIT NO: 12010106
OWNER'S NAME: JOSEPH JUNSAY 480 ALDO AVE DATE ISSUED:01/15/2012
OIVNER'S PHONE: 4083865400 SANTA CLARA,CA 95054 PHONE NO:(408)370-3082
❑
LICENSED C'ONTRACTOR'S DECLARATION �T
BUILDING PERMIT INFO: BLDG �F ELECT PLUMB'
License Class Lic.# 4�--= Ff..�::.
MECH RESIDENTIAL COMMERCIAL
Contractor Date
I hereby affer€n that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION: REPLACING SEWER LINE BY TRENCH-LESS METHOD
(commencing with Section 7000)of Division 3 of the Business&Professions
Code and that my license is in full force and effect.
I hereby affirm under penalty of perjury one of the following two declarations: t
I 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. Sq.Ft Floor Area 0 al€Ia ion:iQi400
I have and will maintain Worker's Compensation Insurance,as provided for b
p P Y
Section 3760 of the Labor Code,for the performance of the work for which this
pernut is issued. APN Number:37519008.00 J v,- ikdpancy Type:
APPLICANT CERTIFICATION �' 1
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 and state laws relating
to building construction,arid hereby authorize representatives of this city eo enter PERMIT P IFyV�ORI�IS NOT STARTED
upon the above mentioned property for inspection purposes. (We)agree to save WITHIN 1 V- ` '�S OF PERMIT ISSUANCE OR
indemnif,v and keep harmless the City of Cupertino against liabilities,judgments, LAST CALLED INSPECTION.
costs,and expenses which may accrue against said City in consequence of the 180 RA
grantilrg of this permit. Additionally,the applicant understands and will comply ,
with all non-point source regulations per the Cupertino Municipal Code,Section Issued by: Date:
9.13.
Signature Date
RE-ROOFS:
❑ OWNER-BUILDER DECLARATION All roofs shall be'inspected prior to any roofing material being installed.If a roof is
installed without first obtaining all inspection,I agree to remove all new materials for
I hereby affirm that I am exempt from the C'ontractor's License Law for one of inspection.
the following two reasons:
1, is owner of the property,or my employees with wages as their sole compensation, Signature of Applicant: Date:
will do the work,and the structure is not intended or offered for sale(Sec.7044,
Business&Professions Code)
I,as owner of the property,am exclusively contracting with licensed contractors to ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
construct the project(Sea7044,Business&Professions Code).
I hereby affirm under penalty,of perjury one of the following three HAZARDOUS MATERIALS DISCLOSURE
declarations: I have read the hazardous materials requirements under Chapter 6.95 of the
I have and will maintain a Certificate of Consent to self-insure for Worker's California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain
Compensation.as provided for by Section 3700 of the Labor Code,for the compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
performance of the work for which this permit is issued. Safety Code,Section 25532(a)should I store or handle hazardous material.
I have and will maintain Worker's Compensation Insurance,as provided for by Additionally,should I use equipment or devices which emit hazardous air
Section 3700 of the Labor Code,for the performance of the work for which this contaminants as defined by the Bay Area Air Quality Management District I will
maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
permit is issued. Health&Safety Code,Sections 25505,2.5533,and 25534.
I certify that in the perfi�rmance of the work for which this permit is issued,[shall
riot employ any person in any manner so as to become subject to the Worker's Owner or authorized agent:
Compensation laws of California. If,after making this certificate of exemption,I Date:
become subject to the Worker's Compensation provisions of the Labor Code,I must
forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of work's
APPLICANT CERTIFICATION for which this permit is issued(Sec.3097,Civ C.)
I certify that I have read this application and state that the above information is Lender's Name
correct.I agree to comply with all city and county ordinances and state laws relating
to building construction,and hereby authorize representatives of this city to enter Lender's.Address
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 may accrue against said City in consequence of the ARCHITECT'S DECLARATION
granting of this permit.Additionally,the applicant understands and will comply I understand my plans shall be used as public records.
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18. Licensed Professional
Signature Date