B-2018-0921 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2018-0921
20034 W14EATON DR CUPERTINO,CA 95014-2340(316 23 089) MIKE COUNSIL
PLUMBING INC
SAN JOSE,CA 95131
OWNER'S NAME: DATE ISSUED:05/29/2018
OWNER'S PHONE: PRONE NO:(
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO,
License Class C=36 Lic.#7C�2C9 1
Contractor MIKE COUNSIL PLUMBING INC Date 04/30/2019 X BLDG ELECT X PLUMB -
I hereby affirm that I am licensed under the provisions mf Chapter 9(commencing —MECII X RESIDENTIAL_COMMERCIAL
with Section 7000)of Division 3 of the Business&Professions Code and that my
uecuse is in nal farce and effect. JOB DESCRIPTION:
PROPERTY LINE CLEANOUT
1 hereby affirm under penalty of perjury one of tire following two declar.tfons:
1. 1 have and will maintain a certificate of consent to self-insure for Workor's
,\ 2 Compensation,as provided for by Section 3700 of the Labor Cade,for the
Vf(1�1 performance of work for which this not is issued.
I have and will maintain Worker's Compensation Insurance,.s provided for by
Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued. Sq,let Flom-Are.: Valuation:$2375.00
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 31623 089
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 WORI{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.
Signature Data 05/29/2018 Issued by:Jasmine Archbald
Date:05/29/2018
OWNER-BUILDER DECLARATION
I hereby aflirnl that I am exempt Train the Contractor's License Law far one of the RE"
R0oils;
following too reasons: All roots shall be inspected prior to any rooting material being Installed.If a root'is
1, I,as owner of the property,or my employee with wages as their sole nstalled without first obtaining an inspection,1 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)
2, f,as owner of the property,am exclusively contructing with licensed Signature ofApplicaue
contractors to construct the project(Sea 7044,Business&Professions Code). Date:05/29/2018
1 hereby affirm under penalty orperjury one of the following three dechurntionsu ALLROOF COVERINGS TO BE CLASS"A"Oil 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 ofthe work for which this permit is issued. HAZARDOUS MATERIALS DISCLOSURE
2. I have and will maintain Worker's Componsatiml insurance,as provided for by I have read the hazardous materials requirements trader Chapter 6.95 of the
Section 3700 of the labor Cade,for the performance of the work for which this California Health&Safety Code,Sections 25505,25533,r it 25534.I will
permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
s. 1 certify that in the performance of the work for which this pennit is issued,I Hedth&Safety Code,Section 25532(x)should I store or handle 11nz:rdous
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
'r contnmllmnts as defined by the Bay Arca Air Quality Management District 1
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 became subject to the Worker's Compensation provisions of the the Health&Safety Cade,Sections 25 95,25533,and 25534.
Labor Code,I must forthwith comply with such provisions or this permit shall
be deemed!revoked. Owner or authorized agent:
APPLICANT CERTIFICATION Date:05/29/2018
I certify that I have read this application and state that the above information Is CQNSTRUCTIQN LENDIVG 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 MunicipalARCHITEC'T'S DECLARATION
Code,Section 9.16. I understand my plans shall be used as public records.
Signature Date 05/2W2018 Licensed
Professional