13060150 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10601 MADERA DR CONTRACTOR:BENJAMIN FRANKLIN PERMIT NO: 13060150
PLUMBING
OWNER'S NAME: BROWN RICHARD C AND JUNE M TRU 22 DIGITAL DR DATE ISSUED:06/18/2013
OWNER'S PHONE: 4088928029 NOVATO,CA 94949 PHONE NO:(415)506-0400
❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG F ELECT r– PLUMB
License Class Lic.#
MECH F RESIDENTIAL I— COMMERCIAL
Contractor Date
I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION: INSTALL 2 WAY CLEAN OUT,REPLACE KITCHEN LINE,
(commencing with Section 7000)of Division 3 of the Business&Professions AND
Code and that my license is in full force and effect. 6FT DRAIN REPAIR UNDER HOME
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.
I have and will maintain Worker's Compensation Insurance,as provided for by
Section 3700 of the Labor Code,for the performance of the work for which this Sq.Ft Floor Area:0 Valuation:$9000
permit is issuCd.
APPLICANT CERTIFICATION APN Number:32635060.00 Occupancy Type:
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,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save PERMIT EXPIRES IF WORK IS NOT STARTED
indenuii fy and I:e ;,harmless the City of Cupertino against liabilities,judgments,
costs,and expcn .,which may accrue against said City in consequence of the WITHIN 180 DAYS OF PERMIT ISSUANCE OR
granting of this permit. Additionally,the applicant understands and will comply 180 DAYS FROM LAST CALLED INSPECTION.
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18.
Issued by: Date:
Signature Date
❑ '"A N'ER-BUILDER DECLARATION
RE-ROOFS:
I hereby;ff i rnl .;:;t lam exempt from the Contractor's License Law for one 0f All roofs shall be inspected prior to any roofing material being installed. If a roof is
the following hi o reasons: installed without first obtaining an inspection,I agree to remove all new materials for
I,as owner of the property,or my employees with wages as their sole compensation, inspection.
will do the woi k.aiul the structure is not intended or offered for sale(Sec.7044,
13u;u,CSs,� Prot.scions Code) Signature of Applicant: Date:
1,as owner ol'!! rroperty,am exclusively contracting with licensed contractors to
construct the 1-r t(See.7044,Business&Professions Code). ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
I hrrrt r a l!i r ler penalty of perjury one of the following three
1 have and will maintain a Certificate of Consent to self-insure for Worker's HAZARDOUS MATERIALS DISCLOSURE
Com pen sit t ion.:i,,,!ovided for by Section 3700 of the Labor Code,for the I have read the hazardous materials requirements under Chapter 6.95 of the
pr!' : wi,, o; work for which this permit is issued. California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain
I h::\r an,! ;: humin Worker's Compensation Insurance,asprovided for by compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
S it; Labor Code,for the performance of the work for which this Safety Code,Section 25532(a)should I store or handle hazardous material.
Additionally,should I use equipment or devices which emit hazardous air
I'`"'t t"' "" contaminants as defined by the Bay Area Air Quality Management District I will
rformance of the work for which this permit is issued,I shall maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
1 11 empi, ci son in any manner so as to become subject to the Worker's Health&Safety Code,Sections 25505,25533,and 25534.
('(,mpensatioii !., .;of California. If,after making this certificate of exemption,I
I:::ome r.:' c Worker's Compensation provisions of the Labor Code,I must Owner or authorized agent:
G,:,hwitl h such provisions or this permit shall be deemed revoked. Date:
APPLICANT CERTIFICATION CONSTRUCTION LENDING AGENCY
I c:rtify t' ::: I n•ad this application and state that the above information is I hereby affirm that there is a construction lending agency for the performance of work's
c. :ect. : ugly with all city and county ordinances and state laws relating for which this permit is issued(Sec.3097,Civ C.)
t. ouildii ion,and hereby authorize representatives of this city to enter Lender's Name
is on the oned property for inspection purposes.(We)agree to save
lemnif, armless the City of Cupertino against liabilities,judgments, Lender's Address
<ts,ant' itich may accrue against said City in consequence of the
gr:mting� it.Additionally,the applicant understands and will comply ARCHITECT'S DECLARATION
Kith all n it regulations per the Cupertino Municipal Code,Section
9''8. I understand my plans shall be used as public records.
nature Date Licensed Professional