12050041 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 20716 GARDEN PLACE CT CONTRACTOR:DEMPSTER PLUMBING PERMIT NO: 12050041
OWNER'S NAME: BOYLE JACQUELINE E 1639 POMONA AVE DATE ISSUED:05/03f2012
OWNER'S PHONE: SAN JOSE,CA 95110 PHONE NO:(408)295-3911
LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL UCOhiAlERC1AL
License Class(f Lie.N gl—Sb 9 REPLACE WATER SERVICE FROM METER TO HOUSE W/
'_dZ5�n 1/ J Date/'—/" - ! Z TYPE
Contructor-1JL COPPER PIPING
1 hereby affirm that 1 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.
I hereby affirm under penalty of perjury one of the following two declarations:
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 whichthis permit is issued. Sq.Ft Floor Area: Valuation:$200
1 have and will maintain Worker's Compensation Insurance,as provided for by
Section 3700 of the Labor Code,for ate performance of the work for which tlhis APN Number:36230062.00 Occupancy Type:
permit is issued- rr, /�
APPLICANT CERTIFICATION - '
I certify that l have read this application and slate that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED
correct. I agree to comply with all city and county ordinances and state laws relating WITHIN 180 DAYS OF PERMIT ISSUANCE OR
to building construction,and hereby authorize representatives of this city to enter
upon he above mentioned properly for inspection purposes. (we)agree to save 180 DA M LAST CALLED INSP C ION.
indemnify and keep harmless the City of Cupertino against liabilities,judgments, ,
costs,and expenses which may accrue against said City in consequence of We
granting ofthis permit. Additionally the upplicant understands and will comply Issued by: G Date.
with all non-point source regulati pe the Cupertino Municipal Code,Section
9.18.
/ 4
RE-ROOFS:
Signature Date /L All roofs shall be inspected prior to any roofing material being installed.If a roof is
installed without first obtaining an inspection,I agree to remove all new materials for
inspection.
❑ OWNER-BUILDER DECLARATION
Signature of Applicant: Date:
I hereby affirm that 1 am exempt from the Contractor's License Lew for one of
the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
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 sole(Sec.7044,
Business&Professions Code)
I,as owner of the property.am exclusively contracting with licensed contractors to IIA7,ARDOUS MATERIALS DISCLOSURF,
construct the project(Sce.7044,Business&Professions Code). 1 have read the hazardous materials requirements under Chapter 6.95 of the
California Health&Safety Code,Sections 25505,25533,and 25534. twill
1 hereby affirm under penally of perjury one of the following three maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
declarations: Health&Safety Code,Section 25532(x)should I store or handle hazardous
I have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally,should I use equipment or devices which emit hazardous
Compensation•as provided for by Section 3700 of the Labor Code,for the air contaminants as defined by the Bay Area Air Quality Management District 1
performance of the work for whichthis permit is issued. will maintain compliance with the Cupertino Mu pa ode.Chapter 9.12 and
1 have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code.Sections 25 05,25 3 nd 25
Section 3700 of the Labor Code,for die performance of the work for which this
Owner or authorized agent: Dale:
permit is issued.
1 certify that in the performance of the work for which this permit is issued,I shall
not employ any person many manner so as to become subject to the Worker's
Compensation laws of California. If,after making this ceniftcate of exemption,I CONSTRUCTION LENDING AGENCY
become subject to the Worker's Compensation provisions of the Labor Code,I must I hereby affirm that there is a construction lending agency for the performance of
forthwith comply with such provisions or this permit shall be deemed revoked. w'ork's for which this permit is issued(Sec.3097•Civ C.)
Lender's Name
APPLICANT CERTIFICATION Lender's Address
I certify that 1 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,and hereby authorize 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, ARCIIITF.CT'S DECLARATION
costs,and expenses which may aceme against said City in consequence of the I understand my plans shall be used as public records.
granting of this permit.Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section Licensed Professional
9.18.
Signature Date
GENERAL PERMIT APPLICATION M E P
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 m ' A w
CUPERTINO (408)77na7-3228•FAX(408)A77-3333.• buildinGcuoeftino.orG v` (v_
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CONTCR NAME ,a R i4 LICENSE NUMBIIL[�Jlrj/Sof LICENSE i)P/EJ� ) BIS LIC 4
COMPANY NAME f1e ��Vw-bt ^ l E-0iM./-LS. Drt Cv /CT Lits Com— FAXgay 2&3Y/1
STREET ADDRESS CITY,STATE,Z8 PFIONE 1
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ARCIMCTIENGINEFA NAME LICENSE NUMBER BUS.DC M
COMPANY NAME' E-MAD. FAX
STREET ADDRESS ' CRY.STATE IIP PRONE
USEOF mDUPLIX [3MULTLFAMB.Y FROB2TINWIDLVID ❑ YES PROIELTN ❑YES LSTBEWMAN ❑YES
RUO.OINQ COMMER[W. e ^ URBANINTERFACEARTA NO FLOOD ZONE NO EIOD.ERROMET wo
OFSCAIPTSON OF WORK R L�f_� W G.-t-GI- .S P-P U i G �j.f'p��'I WeAe- ' /c, Til e
TOTAL VALUATION: 2QO Q RECEIVED BY: ^/
By my sigaaGam below,I terrify to each of the following: I am the property owner or amhcrized agent to act on the property owD'er'svbehalf I have red this
application and the hdb, ation I have provided is at have read the Description of Work and verify it is accrostc. I agree to camuly with all applicable local
ardmanee and state laws relating to boil ' g treed I mtharize representatives of Cupertino to cater the above-i. tiflo property for inspection pu(q)oscs.
Signature ofApplient/Agcae Dam: �'" ' ' Z
SUPPLEMENTAL INFORMATION REQUIRED OFFICE USE ONLY
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❑ STANDARD
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❑ MAJOR
MEPMwcApp 2011.doc revised 06121/11