B-2016-2604CITY OF CUPERTINO BUILDING PERMIT
BUILDINGADDRESS:
CONTRACTOR:
PERMIT NO: B-201.6 2604
20600 RODRIGUES AVE CUPERTINQ, CA 95014-2965 (359 11 019)
TATS INC
MISSION HILLS, CA
91346
OWNER'S NAME: DARE JANICE P TRUSTEE
DATE' ISSUED: 08/29/2016 4
OWNER'S PHONE: 408-253-0633
PHONE NO: (408) 227-1630
LICENSED CONTRACTOR'S DECLARATION
BUILDING PERMIT INFO:
License Class Q--M Lic. #867625
Contractor TATS INC Date 11/30/2017
X BLDG _ELECT X PLUMB
I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing
_ MECH X RESIDENTIAL _ COMMERCIAL
with Section 7000) of Division 3 of the Business & Professions Code and that my
license is in full force and effect:
JOB DESCRIPTION:
REPLACE WATER MAIN SERVICE
I hereby affirm under penalty of perjury one of the following two declarations:
1. 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
permit is issued.
Sq. Ft Floor Area:
Valuation: $9000.00
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
APN Number:
Occupancy Type:
and state laws relating to building construction, and hereby authorize
359 11 019
representatives of this city to enter 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
PERMIT EXPIRES II+' WORK IS NOT STARTED
may accrue against said City in consequence of the granting of this permit.
Additionally, the applicant understands and will comply with all non-point
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
source regulations per the CupertinoMunicip Section 9.18.
180 DAYS FROM LAST CALLED INSPECTION.
Signature ate 8/29/2016
Issued by: Abby Ayensk
OWNER-BUILDE DECLAIt/ATIor
Date: 08/29/2016
I hereby affirm that I am 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. 1, as owner of the property, or my employees with wages as their sole
installed without fust 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. I, as owner of the property, am exclusively contracting with licensed
Signature of Applicant:
contractors to construct the project (Sec.7044, Business & Professions Code).
Date: 8/29/2016
I hereby affirm under penalty of perjury one of the following three declarations:ALL
ROOF COVERINGS TO BE CLASS "A" OR BETTER
m. 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.
HAZARDOUS MATERIALS DISCLOSURE
2. I have and will 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 in 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 Compensation laws of California. If, after making this certificate of
will maintain compliance with the Cupertino Municipal Code, "ter 9.12 and
exemption, I become subject to the Worker's Compensation provisions of the
the Health & Safety Code, Sections 25505, 25533, 25534.
Labor Code, I must forthwith comply with such provisions or this permit shall
be deemed revoked.
-
Owner or authorized agent:
APPLICANT CERTIFICATION
Date: 8/29/2016
1 certify that I have read this application' and state that the above information is
CONSTRUCTION LENDR65"E CY
correct. I agree to comply with all city and county ordinances and state laws
I hereby affirm that there is a construction ding agency for the performance
relating to building construction, and hereby authorize representatives of this city
of work's for which this permit is issued Aec. 3097, Civ C.J
to enter upon the above mentioned property for inspection purposes. (We) agree
Lender's Name
to save indemnify and keep harmless the City of Cupertino against liabilities,
judgments, costs, and expenses which may accrue !against said City in
Lender's Address
consequence of the granting of this permit. Additionally, the applicant understands
and will comply with all non-point source regulations per the Cupertino Municipal
ARCHITECT'S DECLARATION
Code, Section 9.18.
1 understand my plans shall be, used as public records.
Licensed
Signature Date 8129/2016
Professional
CUPERTINO
GENERAL PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE'AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3225, • FAX (408) 777-3333 • building(cDcupertino.ong
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AllEPAlliscApp_2011.doe revised 03/16/11