B-2017-1393CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO: B-2017-1393
21190 CANYON OAK WAY CUPERTINO, CA 95014-6572 (342 59 002) MIKE COUNSIL
PLUMBING INC
SAN JOSE, CA 95131
OWNER'S NAME:
LICENSED CONTRACTOR'S DECLARATION
License Class C_36 Lic. #6y9261
Contractor MIKE COUNSIL PLUMBING INC Date 04/30/2019
I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing
with Section 7000) of Divisioa,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:
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
rformance of the work forwhich 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.
APPLICANT CERTIFICATION
I certify that I have readithis application and state that the above
information is correct. [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 indemnify and keep harmless the
City of Cupertino against liabilities, judgments, costs, and expenses which
may accrue against -said City in consequence of the granting of this permit.
Additionally, the applicant understands and will comply with all non -point
source regulations per the Cupertino. Municipal Code, Section 9.18.
Date 8/21/2017
I hereby affirm that I am exempt from the Contractor's License Law for one of the
following two reasons:
m. I, as owner of the property, or my employees with wages as their sole
compensation, will do the work, and the structure is not intended or offered for
sale (Sec.7044:,Business & Professions Code)
2. I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec.7044, Business & Professions Code).
I hereby affirm under penalty of perjury one of the following three declarations:
m. I have and wili'maintain a Certificate of Consent to self -insure for Worker's
Compensation,ias provided for by Section 3700 of the Labor Code, for the
performance of the work for which this permit is issued.
2. I have and wiWmaintain 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.
3. I certify that in, the performance of the work for which this permit is issued, I
shall' 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 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.
. 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 to building construction, and hereby authorize representatives of this city
to enter upon the abov6imentioned property for inspection purposes. (We) agree
to save indemnify and keep harmless the City of Cupertino against liabilities,
judgments, costs, and expenses which may accrue against said City in
consequence of the granting of this permit. Additionally, the applicant understands
and will comply with all non -point source regulations per the Cupertino Municipal'
Code, Section 9.18.
Signature Date 8/21/2017
DATE ISSUED: 08/21/2017
PHONE NO: (408) 2724900
BUILDING PERMIT INFO:
X_ BLDG —ELECT X PLUMB
_ MECH X RESIDENTIAL _ COMMERCIAL
JOB DESCRIPTION:
REPLACE WATER MAIN SERVICE (SAME LOCATION)
Sq. Ft Floor Area: I Valuation: $14833.00
APN Number: Occupancy Type:
342 59 002
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
Issued by: Jasmine Archbold
Date: 08/21/2017
All roofs shall be inspected prior to any roofing material being installed. If a roof is
installed without fust obtaining an inspection, I agree to remove all new materials for
inspection.
Signature of Applicant:
Date: 8/21/2017
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
HAZARDOUS MATERIALS DISCLOSURE
I have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533, and 25534. I will
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
Health & Safety Code, Section 25532(a) should I store or handle hazardous
material. Additionally, should I use equipment or devices which emit hazardous
air contaminants as defined by the Bay Area Air Quality Management District I
will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and
the Health & Safety Code, S ctions 2550 , 2 533, and 25534.
00v� o thcrized agent
CONSTRUCTION LENDIN NCY
I hereby affirm that there is a construction lending agency for the performance
of work's for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
Lender's Address
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Licensed
GENERAL PERMIT APPLICATION MEP
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228 • FAX (408) 777-3333 • bui!dino(EDcupertino.orct misc
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Run.DING: fo CO1'WmR.CLAL URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑ NO
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DESCRIPTION OF WORK f� Vl
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By my signature bel'o , I certify to each ofthe following:
I am the property owner or authorized agent to act on the prope�,'owner's behalf. I have read this
application and the information I have provided is correct.
I Dave read the Description of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating t building constructio
I authorize representatives of Cupertino to enter the above-identifie property for inspection purposes.
Signature of Applicant'Agent:
Date:
SPPLENTSNNTAL DjgM.MATION
REQUIRED
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A7EPA1isc.4pp_2011.doc revised 05/21111