B-2018-1092 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS; CONTRACTOR: PERMIT NO:13-2018-1092
7422 FALLENLEAF LN CUPERTINO,CA 95014-5805(359 28 024) MARTI'S PLUMBING
SERVICE INC
SAN JOSE,CA 95125
OWNER'S NAME:Forsyth Myron G Trustee DATE ISSUED:06/28/2018
OWNER'S PHONE: PHONE NO:(408)315-3190
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class PLUMBING Lid.#258020
Contractor MARTI'S PLUMBING SERVICE INC Date 12/31/2019 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;
I hereby affirm under penalty o£perJury one of the following two declm•ntiens: TRENCH-LESS SEWER(40')PROPERTY CLEANOUT
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.
z. I have and will maintain Worker's Compensation Insurance,as provided for by
Section 3700 of the Labor Code,for die performance of the work for which this
pla mit is issued. Sq.Ft Fluor Area: Valuation:$12500,00
APPLICANT CERTIFICATION
I certify that I have read this application and slate 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 35929 024
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,thea�icantun derstands and will comply with all non-point
source regulati nCupertino Municipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
Signature /2U Data Issued by:Jasmine Archbold
Date:06/28/2018
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of theRE-ROOFS:
following two reasons: All roofs shall be inspected prior to any roofing material being installed.Its roof is
1. I,as owner of the property,or my employees with wages as their sole installed without first obtaining
(�' p inspection,1 agree to remove all new materials for
work,compensation,will do the w ,and the.structure a
tructure is not intended or offered for etion.
sale(Scc.7044,Business&Professions Code)
z. 1,as owner of the property,am exclusively contracting with licensed Signature of Applicant:
contractors to consnlef tile project c,7044,Business&Pro essmns Code). Dam
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 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 haw 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 Code,for tine 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 permit is issued,I Health&Safety Code,Section 25532(x)should I store or handle hazardous
shall not employ n material.Additionally,should 1 use equipment or devices which emit hazardous
p y a y person in any manner so as to become subject to the atr'ontxminants as defined by the Bny Area Air Quality Management➢tstrtct I
Worker's Compensation laws of California.If,after making this oarli0cate of will mnfmain compliance with the Cape -Municipal Code,Chnpter 9.12 and
exemption,l become subject to the Worker's Compensation provisions o£the the Health&Safety Code,Se•buns 255n5,25533,and 25534.
Labor Code,I must forthwith comply with such provisions or this permit shall
be deemed revoked. - Owner or authorized agent:
APPLICANT CERTIFICATION Data:
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 ARCIDTECT'S DECLARATION
Code,Section 9.18, 1 understand my plans shall be used as public records.
SignatureDate Licensed
Professional