B-2016-3071 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2016-3071
1185 YORKSHIRE CT CUPERTINO,CA 95014-4967(362 11 006) MIKE COUNSIL
PLUMBING INC
SAN JOSE,CA 95131
OWNER'S NAME: PHILLIPS BRIAN G AND SYLVUX. DATE ISSUED:11/08/2016
in.
OWNER'S PHONE:408-257-2345 �r® PHONE NO:(408)272-4900
111,
LICENSED CONTRACTOR'S DECLARATION toBUIIL INE PE'RNIIT INFO:
License Class C36 Lic.#679261
Contractor MIKE COUNSIL PLUMBING INC Date 04/30/2017 X BLDG _ELECT X PLUMB
MECH X RESIDENTIAL_COMMERCIAL
I hereby affirm that I am licensed under the provisions of Chapter 9(co nvrienging
with Section 7000)of Division 3 of the Business&Professions Code and that my
license is in full force and effect. JOB DESCRIPTION:
REPLACE MAIN SEWER/LATERAL CLEAN OUT;INSTALL HOUSE
I hereby affirm under penalty of perjury one of the following two declarations: CLEAN-OUT
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.
G " 2. 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:$39199.00
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 362 11 006
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 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 applicant understands and will comply with all non-point
source regulations per the Cupertino Municipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
,S gnatur ,� Date 11/8/2016 Issued by:Kim Dunbar
Date: 11/08/2016
OWNER-BUILDER DECLARATION
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
i. 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. 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:11/8/2016
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 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,Chapter 9.12 and
exemption,I become subject to the Worker's Compensation provisions of the the Health&Safety Code,Sections 25505 25533,and 25534.
Labor Code,I must forthwith comply with such provisions or this permit shall
be deemed revoked. Qwner or authorized agent:
APPLICANT CERTIFICATION Date:11/8/2016
I certify that I have read this application and state that the above information is CONSTRUCTION LENDING AGENCY
correct.I agree to comply with all city and county ordinances and state laws I hereby affirm that there is a construction lending agency for the performance
relating to building construction,and hereby authorize representatives of this city of work's for which this permit is issued(Sec.3097,Civ C.)
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. I understand my plans shall be used as public records.
Signature Date 11/8/2016 Licensed
Si
9 Professional
GENERAL PERMIT APPLICATION MEP
• � COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
'4" 10300 TORRE AVENUE•CUPERTINO,CA 95014-3255
(408)777-3228•FAX(408)777-3333•buildinc alcupertino.orq I'fl 's c
CUPERTINO
i 4J
PLUMBING ❑MECHANICAL ❑ELECTRICAL I=1 MISCELLANEOUS
PROJECT ADDRESS /`
10) 0 C i"c•t g li� APN#
OWNERNAME $ f fr r PS PH NEo5) E-MAIL
STREET ADDRESS v 1 ITY, 15TATE,ZIP FAX
CONTACT NAME n_: aS / r PHONE E-MAIL
CO ei+ICAC
STREET ADDRESS CITY,STATE,ZIP FAX
❑OWNER ❑ OWNER-BUILDER 0 OWNER AGENT 0 CONTRACTOR CONTRACTOR AGENT 0 ARCHITECTS ❑ENGINEER 0 DEVELOPER 0 TENANT
CONTRACTOR NAME D s L /1,l 56 et LICENSE NI IMBED-la r ( LICENSE TYPE ^ 3,(:) BUS.LIC# F�
COMPANY NAME /�,tke. Co N N5; E MAIL `7 i ` len /�! M ci��IM�ICdD FAX
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STREET ADDRESS �f n l` CITY STATE,Z®5e {(�J `j% tiny (
P r'sNFr) 2,1 q L - 106
ARCHITECT/ENGINEER NAME ` LICENSE NUMBER BUS.LIC#
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF IXSFD or DUPLEX ❑ MULTI-FAMILY PROJECT IN WILDLAND El YES PROJECT IN 0 YES IS THE BLDG AN 0 YES
BUILDING: ❑COMMERCIAL URBAN INTERFACE AREA 0 NO FLOOD ZONE 0 NO EICHLER HOME? 0 NO
DESCRIPTION OF WORK
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TOTAL VALUATION: �W I
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Bymysignature below,I certifyto each of the following: I am the propertyowner or authorized agent to act.n the roe owner's behalf. I have read this
� b p P rtY
application and the information 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 property for inspection purposes.
Signature ofApplicant/Agent Date: I
SUPPLEMENTAL INFORMATION REQUIRED OFFICE USE ONLY
OVER-THE COL1 'IER , ,N
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El STANDARD
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❑;`LARGE,
MEPMisc.App_2011.doc revised 06/21/11