B-2018-1158 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2018-1158
21593 CASTLETON ST CUPERTINO,CA 95014-4702(356 18 059) SIMPLY GREEN
PLUMBING INC
SAN JOSE,CA 95124
OWNER'S NAME: DATE ISSUED:07/10/2018
OWNER'S PHONE: PHONE No:(408)358-6446
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class C-36 Lid.#943556
Contractor SIMPLY GREEN PLUMBING INC Date 021291202 0 X BLDG—ELECT X PLUMB
I hereby affirm that 1 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:
RE-PIPE WATER LINES UNDER HOUSE 12 FIXTURES-(COPPER)
I hereby affirm under penalty of perjury one of the following two declarations:
r. I have and will maintain a certificate o£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. 1 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:$19383.00
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 356 18 059
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 WORI{IS NOT STARTED
may,accrue against id City In consequence of the granting of this permit. WITHIN 180 DAYS OF PERMIT ISSUANCE OR
Additionally,the ap Old
��.d.,
omply with all non-point
source regulations Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
SignatureData 07/10/2018 Issued by:Jasmine Archbold
Data:07/10/2018
OWNER-BUILDER DECLARATION
I hereby attire that turn exempt from the ContractoNs License Law for one of the 11F-ROOFS:
following two reasons: All roofs shall be inspected prior m any roofing material being installed.If a our is
t. I,as owner of the property,or my employees with wages as their sole instelied without First obtaining an iuspcetion,I agree to remove all new materials for
compensation,will do the work,and the structure is not intended or offered for inspection.
sale(Sm.7044,Business&Professions Code)
z. 1,as owner of the property,am exclusively contracting with licensed Signature ofApplicent:
contractors to construct the project(Sec,7044,Business&Professions Code). Date:07/1072018
I hereby elan under penalty of perjury cue of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
1. 1 have and will maintain a Certificate of Consent to self-insure for Workers
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
2. 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 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 Cupertino Municipal Code,Chapter 9.12 and the
s. 1 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 any person in any manner so as to become subject to the material.Additionally,should I use equipment or devices which emit hozardous
air contaminants as defined by the Be Area Air Quality Management District I
Worker's Compensation laws of California.If,after making this certificate of will maintain compliance with the C ertinenicipal C —lurplxt^9'l'2 and
emption,I become subject to the Worker's Compensation provisions of the the Health&Safety Cod ections , 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:0 711 0/20 1 8
I certify that I have read this application and state that the above information is CONST N LC D AGENCY
cc
content.I agree to mply with all city and county ordinances and slate 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 07/10/2018
Professional