B-2018-0564 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2018-0564
1128 DERBYSHIRE DR CUPERTINO,CA 95014-5072(362 21 033) R B TRAVIS
LIVERMORE,CA 94551
OWNER'S NAME:ISHIDA LILLIAN Y TRUSTEE DATE ISSUED:04/06/2018
OWNER'S PHONE: PHONE NO:(925)443-8304
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class C36 Lie.#671157
Contractor R B TRAVIS Date 0613112019 X BLDG—ELECT X PLUMB
MECH X RESIDENTIAL COMMERCIAL
I hereby affirm that I nm licensed tinder the provisions of Chapter 9(commencing
with Section 7000)of Division 3 at the Business&Professions Code and that my
license is in full force and effect. JOB DESCRIPTION:
REPLACE SEWER LATERALAT PROPERTY LINE
I hereby affirm tinder 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.
rI haveand will maintain Worker's Compensation Insurance,as provided for by
7r((—Section 3700 of the Labor Code,for the performance of the work for which this
(,- permit is issued. Sq.Ft Fla.,Are.: Valuation:$4000.00
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above APN Number: Occupancy Type:
Information is correct.I agree to comply with all city and county ordinances 362 21 033
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 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 04-05-2018 Issued by:Kim Dunbar
Date:04/06/2018
OWNER-BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractor's License Law for one of the RE-ROOFS,
following two reasons: Ail roofs shall be inspected prior to nuy roofing material being installed.If a roof is
r. 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 afford for inspection,
sale(See.7044,Business&Professions Code)
1. I,as owner of the property,am exclusively contracting with licensed Signature o£Applicant:
contractors to construct the project(Sec.7044,Business&Professions Code). Date:04-05-2018
1 hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
r. 1 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
z. I have and will maintain Worker's Compensation Insuronce,as provided for by I have read the hazardous materials requirements carder Chapter 6.95 of the
Section 3700 of the Labor Code,for the performance of the work for which this California Health&Safety Code,Sectimrs 25505,25533,and 25534.I will
permit is issued. lir aintain 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 m•handle hazardous
shall not employ n on in r so as to become sulhi-t to the material.Additionally,Should I use equipment m-devices which emit hazardous
p y a y peri any mantic r contaminants as defined by the Bay Area Air Quality Management District 1
Worker's Compensation laws of California.If,after making this certificate of will maintain complin nee with the Cupertino Muntefp it Code,Chapter 9.12 and
exemption,I become subject to the Worker's Compensation provisions of the the Health&Safety Cade,Sections 25505,25533,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:04-05-2018
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 04-05-2018 Professional