B-2016-2552 i
CITY OF CUPERTINO BUILDING PERMIT'
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2016-2552
894 BROOKGROVE IN CUPERTINO,CA 95014-4634(375 39 039) MIKE COUNSIL
PLUMBING INC
SAN JOSE,CA 95131
OWNER'S NAME: LIL r LONG-ZUU DATE ISSUED:08/19/2016
OWNER'S PHONE:6619-294-0112 PHONE NO:(408)272-4900
LICENSED CONTRA JOR'S DECLARATION BUILDING PERMIT INFO
License Class G-36 Lic.# 7 2 1
ContractorMIKE COUNSIL P LUMBING INCDate 04/30/2017 X BLDG _ELECT X PLUMB
_
I hereby affirm that I a licensed under the provisions ofChapter 9(commencing MECH X RESIDENTIAL T COMMERCIAL
with Section 7000)of Division 3 of the;Business&Professions Code and that my
license"is in full force and effect. JOB DESCRIPTION:
REPIPE SFD(COOPER)-FULL;(I)WATER SERVICE;
I hereby affirm under penalty of perjury one of the following two declarations:
1. I have and wil 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 c f the work for which this permit is issued.
I have and wil maintain Worker's Compensation Insurance,as provided for by
Section 3700 f the Labor Code,for the performance of the work for which this
permit is issued, Sq.Ft Floor Area: Valuation:$38000.00
APPLICANT CERTIFICATION
certify that I have reac this application and state that the above
information is correct.I agree to comply with all city and county ordinances APN Number: Occupancy Type:
and state laws relating o building construction,and hereby authorize 375 39 039
representatives of this city to enter upon the above mentioned property for
inspection purposes. e)agree to save indemnify and keep harmless the
City of Cupertino again A liabilities,judgments,costs,and expenses which PERMIT EXPIRES IF WORK IS NOT STARTED
may accrue against said City in consequence of the granting of this permit. WITHIN 180 DAYS OF PERMIT ISSUANCE OR
Additionally,the applic nt understands and will comply with all non-point
source regulations per he Cupertino Municipal Code,Section 9.18, 180 DAYS FROM LAST CALLED INSPECTION.
Signature J4 Date 8/19/2016 Issued by:Abby Ayende
Date:08/19/2016
ONVNER-BUILDERDE N
I hereby affirm that exempt from the Contractor's License Law for one of the RE-ROOFS:
following two reasons: All roofs shall be inspected prior to any roofing material being installed.If a roof is
1. I,as owner of the property,or my employees with wages as.their sole installed without first obtaining an inspection,I agree to remove all new materials for
compensation will do the work,and the structure is not intended or offered for inspection.
sale(Sec.7044,Business&Professions Code)
z. 1,as owner of the property,am exclusively contracting with licensed Signature of Applicant:
contractors to construct the project(Sec.7044,Business&Professions Code). Date:8/19/201
I hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
1. I have and wil I maintain a Certificate of Consent to self-insure for Worker's
Compensatior,as provided for by Section 3700 of the Labor Code;for the
performance of the work for which this permit is issued. HAZARDOUS MATERIALS DISCLOSURE
2. I have and wil I maintain Worker's Compensation Insurance,as provided for by I have read the hazardous materials requirements under Chapter 6.95 of the
Section 3700 of the Labor Code,for the performance of the work for which this California Health&Safety Code,Sections 25505,25533,and 25534. I will
permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
3. I certify that ffi the performance of the work for which this permit is issued,I Health&Safety Code,Section 25532(a)should I store or handle hazardous
shall not employ any person in any manner so as to become subject to the material. Additionally,should I use equipment or devices which emit hazardous
air contaminants as defined by the Bay Area Air Quality Management District I
Worker's Con pensaton laws of California. If,after making this certificate of will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and
exemption,I I iecome subject to the Worker's Compensation provisions of the the Health&Safety Code,Sections 255 ,1 nd 25534.
Labor,Code,I must forthwith comply with such provisions or this permit shall -
be deemed revoked. J owner or authorized agent:
APPLICANT CERTIFICATION Date:8/19/2016
I certify that I have rea this application and state that the above information is N TR TIONEN Y
correct.I agree.to com ly with all city and county ordinances and state laws I hereby affirm that there is a constr ending agency for the performance
relating to building con 3truction,and hereby authorize representatives of this city of work's for which this permit is issued(Sec.3097,Civ C.)
to enter upon the abov mentioned property for inspection purposes. (We)agree Lender's Name
to save indemnify and <eep harmless the City of Cupertino against liabilities,
judgments,costs,and xpenses which may accrue against said City in Lender's Address
consequence of the gr nting of this permit. Additionally,the applicant understands
and will comply with al
non-point source regulations per the Cupertino Municipal ARCHITECT'S DECLARATION
Code,Section 9.18. I understand my plans shall be used as public records.
Licensed
Signature Date 8/19/2016 Professional
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GENERAL PERMIT APPLICATION MEP
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE-CUPERTINO,CA 95014-3255
CUC�ERTCN (408)777-3228•FAX(408)777-3333•buildingft-cupertino.org misc
PLUM� `BINCx MECHANICAL ELECTRICAL ` MISCELLANEOUS
PRGJEG`I'ATIDRESS {1 roo e- L e- APN# �RV '03q
OWNERNAME
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STREET ADDRESS ,STATE,ZIP FAX
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CONTACT NAME f PONE E-
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®OWNER 0 O ER-BUILDER ®OWNER AGENT KRAIT.. ❑CONTRAL.TORAGENT ❑ ARCHITECT ❑ENGINEER ® DEVELOPER ®TENANT
CONTRACTORNAME : ( LICENSE NUMBER LICENSE YPE BUS.LIC ^L���d
COMPANY NAME /' ( r E . r FAX J Y
STREET ADDRESS .STATE, IP PHONE
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ARCIMCT/MONEF R NAME LICENSE NUMBER BUS.LIC#
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF SF .DUPLEX._ ❑ MULTI-FAMll.Y PROJECT IN 1VILDLAND [] YES PROTECT 1N ❑YES IS THE BLDG AN YES
BUILDING- '®CO RCIAL - URBAN INTERFACE AREA [R-NO PLOOD ZONE �No EICHLER HOME? No
DESCRIPTION OF WO r
0(J C
I
TOTAL VALUATION: GQ RECEIVED BY;
By my signature below,I ccrtif3eto each of the following: I am the property owner or authorized agent to act on the property owner's h hal£ I have read this
application and the'aformation I have provided is correct. I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating to building construction. I authorize representatives of Cupertino to enter the above-identified prop",for inspection purposes.
Signature of Applic tlAgent: Date: ' ► �` c
SUPPLEME AI 'TION REQUIRED OFFICE USE ONLY
❑ OVER-TRE-COUNTER
0 EXPRESS
W
D STANDARD
LARGI
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MEPMascApp_2011.doe revised 06121111
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