12100151 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 888 BROOKGROVE LN CON\fRACI'OR:DRAIN DOCTOR PERMITNO: 12100151
OWNFR'SNANIF: MURPHYHELENCTRUSTEE 480ALDO AVE DATE ISSUED: 10/182012
OWNER'S 1.11ONE: 4082573392 SANTA CLARA,CA 95054 PHONE NO:(408)370-3083
❑ ' LICENSED COYfRACfOR'S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT r PLUMB
License Class Lie.q
M EC11 RESIDENTIAL J COMM, CLL J
Contractor Date
I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION: INSTALLING PROPERTY LINE CLEANIZ
(commencing with Section 7000)of Division 3 of the Business&Professions
Code and that my license is in full force and effect.
1 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 A.
performance of the work for which this permit is issued, va
1 have and will maintain Worker's Compensation Insurance,as provided for by Sq.Pt Floor Area:0 rV,._alualipii:$3450'
Section 3700 of the Labor Code,for the performance of die work for which this
permit is issued APN Number:37539040.00 CjF� ZOcupancy.1,)pe:
A PP1-IC.kY1'CE RTI FIC TION --
I certify that I have read[his application Emit state that(tic above information is
correct.I agree to comply with all city and county ordinances and state lases relating PERMIT EXPIRES LF ORK IS NOT STARTED
to building construction,and hereby authorize representatives of this city to enter ..�ra0.
upon the above mentioned property for inspection purposes. (We)agree to save WITHIN 180 DA S O PERMIT ISSUANCE OR
indemnifyand keep harmless the City of Cupertino against liabilities,judgments. 180 DAYS FROM LAST CALLED INSPECTION.
costs•and expenses which may accrue against said City in consequence of the
granting of this permit. Additionally,the applicant understands mid will comply
with all non-point source regulations per the Cupertino Municipal Code,Section Issued bv: Date:
9.18.
Signature Date
RE-ROOFS:
❑ ON'NER-13IJILDFR DISCI,ARAI'ION All roofs shall be inspected prior to any roofing material beiig installed.If a roof is
installed without first obtaining an inspection,I agree to remove all new materials for
hereby affirm that I am exempt from the Contractor's License Law for one of inspection.
the following two reasons: .
1,as owner of the property,or my employees with wages as their sole compensation, Signature of Applimm: Date:
will do the work,and the structure is not intended or offered for sale(Scc.7044,
Business&Professions Code)
1,as owner of the property,am exclusively contracting with licensed contractors to ALL ROOF COVERINGS TO BE CLASS"A"OR BE PIER
cons[mct the project(Sec.7044,Business&Professions Code).
1 hereby offurm under penalty of perjury ane of the following three IIA%ARDOUS MATERIAI S DISCLOSURE
declarations: I have read the hazardous materials requirements under Chapter 6.95 of the
1 have and will maintain a Certificate of Consent to self-insure for Worker's California Health&SafetyCode.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 Health&
performance of the work for which Otis permit is issued. Safety Code,Section 255321n)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
permit is issued. maintain compliance with the Cupertino Municipal Code.Chapter 9.12 and the
Ilealth&Safety Code,Sections 25505.25533.and 25534.
1 cenily that in the performance of the work for which this permit is issued,I shall
not employ any person in any manner so as to become subject to the Worker's (honer or authorized agent:
Compensation laws of California. If,aficr making Otis cenificate 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. CONS'IRI1C1'I0N LENDING AGENCY
I hereby affirm Ihm there is a construction lending agency for the performance of tiork's
APPI,ICSYI'C1.R'1'IPICAI'ION lot 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 Taws 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 accme against said City in consequence of the ARCII ITECf'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 Dale