B-2018-1068 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2018-1068
19703 LA MAR DR CUPERTINO,CA 95014-3308(369 10 020) OVERMILLER INC
CONCORD,CA 94520
OWNER'SNAME:Bit—PilonrenaTTIled- DATE ISSUED:06/26/2018
OWNER'S PHONE: PHONE NO:(925)799-2122
LICENSEDT R' DE LARATION BUILDING PERM1TINFO:
License Class C-36C-42 Lie.#323839 X BLDG—ELECT X PLUMB
Contractor OVERMILLER INC Date 07/31/2018 —
MECH X RESIDENTIAL COMMERCIAL
I hereby affirm that I an licensed under the provisions of Chapter 9(commencing — —with Section 7000)of Division 3 of the Business&Professions Code and that my
license is in full force and effect. JOB DESCRIPTION:
PROPERTY LME CLEANOUT
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
performance ofthe work for which this permit is issued.
1 have and will maintain Worker's Compensation Insurance,as provided for by
Section 3700 of the Labor Code,for the performance ofthe work for which this
permit is issued. Sq.Ft Floor Are.: Valuation:$3975.00
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 369 10 020
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 Date 06/2612018 Issued by:Jasmine Archheld
Date:06/26/2018
Ow E -RI.1LDER D E CL RATIO
I hereby affirm that I am exempt from the Contractor's License Law for one ofthe RE-ROOFS:
following two rensons: All root's shall be ins{hected prior to any roofing material being installed.its root'is
1. 1,as owner of the property,or my employees with wages as into sole installed Without first obtaining an inspection,l agree to remove all new materials for
compensation,will do die work,and the ahmemre 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 o£Applicand
contractors to construct the project(Sec.7044,Business&Professions Code), Date:06/26/2018
1 hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
1. I have and will maintain a Certificate of Consent to sel£-Iname 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 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. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
s. I certify that in the performance of the work for which this perm(t is issued,I Health&Safety Code,Section 25532(x)should I store or handle hanardous
shall not employ n n in any manner so as to become subject to the material.Additionally,should I rise equipment or devices which emit hazsudous
p y n y on la y J air emit ned...is as defined by the Bay Area At.-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 ofthe the Herdth&Safety Code,Sultans 25505,25533,and 25534.
Labor Code,1 must forthwith comply with such provisions or this permit shall –_
be deemed revoked. Owner or authorized ag I.
APPLICANT CERTIFICATION Data:06/26!2018
I certify that I have read this appliCalon ando ate that the above information Is CON & .TION 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 ARCHITEC7"5 DECLARATION
Code,Section 9.18. 1 understand my plans shall he used as public records.
Licensed
Signature Date 06/26!2018 Professional