B-2018-0856 CITY OF CUPERTINO BUILDING PERMIT
BUILDINGADDRESS: CONTRACTOR: PERMIT NO:B-2018-0856
10374 SAN FERNANDO AVE CUPERTINO,CA 95014-2833(357 12 043) GLEN GILBERT
SAN JOSE,CA 95154
OWNER'SNAME: DATE ISSUED:05/17/2018
OWNER'S PHONE: PHONE NO:(
LICENSED CONTRACTOR'S 'C BUILDING PERMIT INFO:
License Class C-42 Lic.#677475
Contractor GLEN GILBERT Date 09/30/2019 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 PROPERTY LINE CLEAN OUT;REPLACE 12'OF PIPE
I hereby affirm under penalty of perjury one of the following two declarations:
r. 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.
issued. Sq.Ft Floor Area: Valuation:$3900.00
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: O—quincy'fype:
and state laws relating to building construction,and hereby authorize 357 12 043
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.
Signature Data 05-17-2018 Issued by:Kim Dunhar
Date:05/17/2018
DINNER-BUILDrR DECLARATION
I hereby affirm that 1 am cxcmpt from the Contractor's License Lav loane of fine RE-ROOFS:
following two reasons: All roof's shall be inspected prior to any roofing material being installed.II'a root'is
a. 1,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(See.7044,Business&Professions Code)
2. I,as owner of the property,am exclusively contracting with liccroscd Signature of Applicant:
contractors to construct the project(Sec.7044,Business&Professions Code). Date:05-17-2018
1 hereby affirm under penalty of perjury one of the following three declarations: ALL 1200E COVERINGS TO BE CLASS"A"OR BETTERr. 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. 1 have and will maintain Worker's Compensation Insurance,as provided for by 1 have read the hazardous materials requirements under Chapter 6.95 or 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 Cupe fine Municipal Code,Chapter 9,12 and file
s. I certify that in the performance of the work for which this permit is issued,I Health&Safety Code,Section 25532(x)should I store or handle hazardous
shall not employ n in an to become sub'ect to the material.Additionally,should I use equipment or devices which emit hazardous
I y any person y manner sees .I ronta
cminants as defined by the Bay Area At,-Quality Management District l
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
APPLICANT CERTIFICATION Date:05-17-2018
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 Municipal ARCHITECT'S DECLARATION
Code,Section 9.18. 1 understand my plans shall be used as public records.
Licensed
Signature Date 05-17-2018 Professional