B-2018-0947 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: - CONTRACTOR: PERMIT NO:B-2018-0947
916 BROOKGROVE LN CUPERTINO,CA 95014-4668(375 39 036) MIKE COUNSIL
PLUMBING INC
SAN JOSE,CA 95131
OWNER'S NAME:
PHONE NO:(408)272-4900
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class C36 Lic.#679261
Contractor MIKE COUNSIL PLUMBING INC Date 04/3012019 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:
INSTALL HOUSE CLEAN-OUT;REPLACE BATHROOMS DRAINS(2)
I hereby affirm under penalty of perjury one of the following two declarations: &WASTED LINES
i. I have and will maintain a certificate o£cousent to self-insure for Worker's -
Compensation,as provided for by Section 3700 of the Labor Code,for the
x performance of the work for which this permit is issued.
I have and will maimm.Worker's Compensation Insurunec,as provided far by
Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued. Sq.Ft Floor Arca: Valuation:$19000.00
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 slate laws relating to building construction,and hereby authorize 375 39 036
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 thg Ly pertino Municipal Code,Section 9.18, 180 DAYS FROM LAST CALLED INSPECTION.
Signature Date 06-01-2018 Issued by:Kim Dunbar
Date:06/01/2018
OWNER-BUILDER DECLARATION
I hereby nftirnr that I am exempt from the Contractor's License Law for one of the R&ROOFS:
following two reasons: All roofs shall be inspected prior to any roofing material being installed,Ira roof is
1. 1,as owner of the property,or my employees with wages as their sole installed withoot first obtaining so 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(See.7044,Business&Professions Cade), Date:06-01-2018
1 hereby affirm under penalty of perjury one of the following three declarations: ALL 1200E COVERINGS TO BE CLASS"A"OR BETTER
1. 1 have and will maintain a Certificate of Conscnt 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
z 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 Cade,for the performance of the work for which this California Health&Safety Code,Sections 25505,25533,and 25534.1 will
permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9,12 and the
a. 1 certify that in the performance of the work for which this permit is issued,l Health&Safety Code,Section 25532(x)should I stare or handle hazardous
shall not employ any person in any manner so as to become subject to the material.Additionally,should 1 use equipment or devices which emit hazardous
air ontaminants 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 t11e the Health&Safety Code,Sections 25505 2 533,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:06-01-2018
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 MunicipalARCHITECT'S DECLARATION
Code,Section 9.18. 1 understand my plans shall be used as public records.
Signature Date 06-01-2018 Licensed
Professional
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2018-0947
916 BROOKGROVE LN CUPERTINO,CA 95014-4668(375 39 036) MIKE COUN SIL
PLUMBING INC
SAN JOSE,CA 95131
OWNER'S NAME: DATE ISSUED:06/01/2018
OWNER'S PHONE: PHONE NO:(
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class C_36 Llc.#679261
Contractor MIKE COUNSIL PLUMBING INC Date 0413012019 X BLDG—ELECT X PLUMB
I hereby aftnin that I nm licensed tinder 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:
INSTALL HOUSE CLEAN-OUT;REPLACE BATHROOMS DRAINS(2)
1 hereby affirm under penalty of perjury one of the following two declarations: &WASTED LINES
t. I have and will maintain a certificate of consent to self-insure for Worker's REV#I PROPERTY LINE-CLEAN-OUT;TRENCHLESS SDR SEWER
Compensation,as provided for by Section 3700 of the Labor Code,for the LINE REPLACEMENT;GAS LINE REPAIR-GALVANIZED STEEL-
performance of the work for which this permit is issued. ISSUED 6/15/2018
z. 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 Flom-Area: Valuation:$19000.00
APPLICANT CERTIFICATION
I certify that 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 slate laws relating to building construction,and hereby authorize 375 39 036
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 Cup rtmo Municipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
Signature Date 06/1512018 Issued by:Kim Dunbar
Date:06/01/2018
OWNER-BUILDER DECLARATION
I hereby aMr.float I am exempt from the Cants—tin•'s License Law far one of the RE-ROOFS:
following two reasons: All roofs shall be inspected In to any roofing material being installed.Ifis roof is
t. 1,as owner of the property,or my employees with wages as theirsole nstalled without first obtaining of inspection,I agree to remove all new materials for
compensation,will do the work,and the stmcmre is not intended a,offered far inspection.
sale(Sec.7044,Business&Professions Code)
x I,as owner of the property,am exclusively contracting with licensed Signature ofApplicanC
contractors to construct the project(Sec.7044,Business&Professions Code). Date:06/152018
1 hereby affirm under penalty of perjury one of the following three declarations:
1. 1 have and will maintain a Certificate of Consent to selRinsurc for Worker's ALL ROOF COVERINGS TO BE CLASS"A"012 BETTER
Compensation,as provided for by Section 3700 of the Labor Code,for the
performance o£the work for which this permit is issued. HAZARDOUS MATERIALS DISCLOSURE
1. 1 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 ofthe 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. m aintain compliance with the Cupertino Municipal Code,Chapter 9.12 and rhe
3. 1 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 25505,25 33,and 25534.
Labor Code,I must furdnwith comply with such provisions or this permit shall
be deemed revoked. Owner or authorized agent:
APPLICANT CERTIFATION Date:06115/2018
I certify that I have read this application and state ICthat the above information is NDINGAgNCY
A
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 06/1512018 Licensed
Professional