11010073 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 18930 BARNHART AVE CONTRACTOR:MR.RESCUE PLUMBING& PERMIT NO: 11010073
ROOTER
OWNER'S NAME: DONALD HOMUTH 4231 BUSINESS CENTER DR STE 12 DATE ISSUED:01/13/2011
FREMONT,CA 94538 PHONE NO:(877)417-3728
C R'S PHONE: 4082523547
❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ELECT r PLUMB
License Class Lic.# MECH r RESIDENTIAL r COMMERCIAL
Contractor Date
JOB DESCRIPTION:REPLACE APPROX 45FT OF MAINLINE SEWER VIA
I hereby affirm that I am licensed under the provisions of Chapter 9 TRECHLESS SEWER
(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. Valuation:$5000
I have and will maintain Worker's Compensation Insurance,as provided for by Sq,Ft Floor Area:0
Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued. APN Number:37533007.00 Occupancy Type:
APPLICANT CERTIFICATION
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 PERMIT EXPIRES IF WORK IS NOT STARTED
to building constriction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save OR
indemnify and keep harmless the City of Cupertino against liabilities,judgments, WITHIN 180 DAYS OF PERMIT ISSUANCE
costs,and expenses which may accrue against said City in consequence of the 180 DAYS FROM LAST CALLED INSPECTION.
granting of this permit. Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section Date:
9.18. Issued by:
Signature Date
RE-ROOFS:
13
OWNER-BUILDER DECLARATION
All roofs shall be inspected prior to any roofing material being installed.If a roof is
I hereby affirm that I am exempt from the Contractor's License Law for one of installed without first obtaining an inspection,I agree to remove all new materials for
the following two reasons: inspection.
I,as owner of the property,or my employees with wages as their sole compensation, Date:
will do the work,and the structure is not intended or offered for sale(Sec.7044, Signature of Applicant:
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(Sec.7044,Business&Professions Code).
I hereby affirm under penalty of perjury one of the following three HAZARDOUS MATERIALS DISCLOSURE
declarations:
I have and will maintain a Certificate of Consent to self-insure for Worker's I have read the hazardous materials requirements under Chapter 6.95 oft e
Compensation,as provided for by Section 3700 of the Labor Code,for the compliance CaliforniawCode,
i h the CupertinoMunicipal Code,Chapter eand 25534. 1 will fain
r 9 1 h 2 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
permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
I certify that in the performance of the work for which this permit is issued,I shall Health&Safety Code,Sections 25505,25533,and 25534.
not employ any person in any manner so as to become subject to the Worker's
Compensation laws of California. if,after making this certificate of exemption,I Owner or authorized agent: 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
APPLICANT CERTIFICATION I hereby affirm that there is a construction lending agency for the performance of work's
I certify that I have read this application and state that the above information is for which this permit is issued(Sec.3097,Civ C.)
correct.I agree to comply with all city and county ordinances and state laws relating Lender's Name
to building construction,and hereby authorize representatives of this city to enter
goon the above mentioned property for inspection purposes.(We)agree to save Lender's Address
wnnify and keep harmless the City of Cupertino against liabilities,judgments,
.sts,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