12060080 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 93113LAZINGWOOD AVE CONTRACTOR:GOGO ROOTER PERMITNO: 12060080
OWNER'S NAME: MURAKAMI SAM S AND HIDEKO 2530 BERRI'ESSA RD STE 509 DATE ISSUED:06/13/2012
OWNER'S PHONE: 4082534129 SAN JOSE.Cl 95132 PHONE NO:(408)282-7026
❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT r PLUMB r
License Class Lic.N
MECH r RESIDENTIAL r COMMERCIAL
Contractor Date
hereby affirm that 1 am licensed under the provisions of Chapter 9 JOB DESCRIPTION:WATER MAIN REPLACEMENT.
(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 which this permit is issued. Sq.Ft Floor Area:0 9lgaqfib'..h$3000
I have and will maintain Workers Compensation Insurance,as provided for by
Section 3700 of the Labor Code,for the performance of the work for which this Q� ffJJ
permit is issued. APN Number:36920017.00 �e
ceuap`ann.Type:
APPLICANT CERTIFICATION
I certify that 1 have read this application and shale that the above information is
correct. I agree tocomply with all city and county ordinances and slate laws entering PERMIT EXPIRE, ' IS NOT STARTED
In building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save WITHIN 180 DAYS''OF RKRMIT ISSUANCE OR
indemnify and keep harmless the City of Cupertino against liabilities,judgments, 180 DAYS FROM ?L.'VS•`I+••CALLED INSPECTION.
costs,and expenses which mayaccrue against said City in consequence of the
�'�
granting of this pemhitL Additionally,the applicant understands and will comply �p
with all non-point source regulations per the Cupertino Municipal Code,Section Issued by: C1.3py.\ Date:
9.18.
Signature Date `•' h
RF.-ROOFS:
❑ OWNER-BUILDER DECLARATION All roofs shall be inspected prior to any roofing material being installed.If a roof is
installed srithoha first obtaining an inspection,I agree to remove all new materials for
I hereby affirm that 1 am exempt from the Contractor's License Law for one of inspection.
the following two reasons:
L as oxner of rhe property,or my employees with wages as their sole compensation, Signature of Applicant: Dale:
will do the%wrk,and rhe structure is not intended or offered for sale(Sec.7044,
Business&Professions Code)
I,as owner ollhe property,am exclusively contracting with licensed contractors t0 ALI.ROOF COVERINGS TO BE CLASS"A"OR BETTER
construct the project(Sec.7044,Business&Professions Code).
1 hereby affirm under penalty of perjury one of the following three IIA%ARDOUS NI ATERIALS 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 Workers California Ilealth&Safety Code,Sections 25505,25533,and 25534. 1 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 Ilealth&
performance of the work for which this permit is issued. Safety Code,Section 25532(a)should 1 store or handle hazardous material.
I have and will maintain Worker's Compensation Insurance,as provided for by Additionally,should 1 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
Permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
I ccnify that in the performance of the work for which this permit is issued,I shall Ilealth&Safety Code,Sections 25505,25533,and 25534.
not employany 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 AGE:NCV
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 ccnify that I have read this application and stale 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
indemnil}'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