B-2018-1160 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2018-1160
10323 GLENCOE DR CUPERTINO,CA 95014-1813(326 30 084) R B TRAVIS INC
LIVERMORE,CA 94551
OWNER'S NAME:NGUYEN HUYEN THI DIEU TRUSTEE DATE ISSUED:07/10/2018
OWNER'S PHONE: PHONE NO:(925)443.8304
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class CC=36 Llc.#EZ1LZ
Contractor R B TRAVIS INC Date 04/30/2020 X BLDG ELECT X PLUMB
I hereby affirm that I am licensed ander the provisions of Chapter 9(commencing —MECH X RESIDENTIAL_COMMERCIAL
with Section 7000)of Division 3 ol'the Business&Professions Code and that my
license is in full force and effect. JOB DESCRIPTION:
REPLACE 40 GAL WATER HEATER-CLOSET
I hereby affirm under penalty of perjury one of the following two declarations:
t. 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.
I 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 Floor Area: Valuation:$1000.00
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 Numher: Occupancy Type:
and state laws relating to building construction,and hereby authorize - 32630 084
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
Additiorldly"the applicant understands and will comply with all non-point
07/10/2018 Issued by:Jasmine Archbold
Date:07/10/2018
OWNER-BUILDER➢ECLAI2ATIm
1 hereby affirm llmt I am exempt fi•mn the Contractor's License Lev for one of the R&ROOFS:
following two reasons: All root's shall be inspected prior to any tooling material being installed.If a roof is
r. 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(8ec.7044,Business&Professions Cade)
i. 1,as owner of the property,am exclusively contracting with licensed Signature of Applicant
contractors to construct the project(Sec,7044,Business&Professions Code). Date:07/10/2018
1 hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTERt. 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. 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. I certify that is the performance of the work for which this permit is issued,I Health&Safely Code,Section 25532(a)should I store or handle hazardous
shall not employ any person in anymanner so as to become subject to the material.Additionally,shoo use equipment or devices which emit hazardous
sit ontaminants as d nim, y e Huy ea Air Quality Management District I
Worker's Compensation laws of California.If,after making this certificate of willmaintaincompltnoee»ith th Cupe t no Munici 2 Cade,Chapter 9.12 and
exemption,I became subject to the Worker's Compensation provisions of the the Hwddn&Sat'ty Co e,Se ins 5 2 3 and 25534.
Labor Code,I most forthwith comply with such provisions or this pcmatshall
be deemed revoked. Owner or authorized age t:
APPLICANT CERTIFICATION Data:0 711 0/2 01 8
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 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 DECI ARAT'I0N
Code,Section 9.18. 1 understand my plans shall be used as public records.
Signature Data 0 711 012 0 1 8 Licensed
Professional