B-2018-1207 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2018-1207
20436 VIA VOLANTE CUPERTINO,CA 95014-6317(316 01 055) STREET PLUMBING
AND ROOTER
SAN JOSE,CA 95128
OWNER'S NAME:Ben-moshe Nir And Nurit DATE ISSUED:07/17/2018
OWNER'S PHONE: PHONE NO:(468)496-1155
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class C36 Lic.#582217
Contractor STREET PLUMBING AND ROOTER Date 12!31/2019 X BLDG ELECT X PLUMB
1 hereby affirm that I am licensed under the provisions at Chapter 9(commencing —MECH X RESIDENTIAL—COMMERCIAL
with Section 7000)of Division 3 blithe Business&Professions Code and that my
license is in fall force and effect. JOB DESCRIPTION:
150 GALLON WATER HEATER-SAME LOCATION AT THE
1 hereby affirm under penalty of perjury one of the following two declarations: GARAGE
s. 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.
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 Floor Area: Valuation:$1650.00
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'li
and state laws relating to building construction,and hereby authorize 316 01 055
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.
nature Date 07117/2018 Issued by:Jasmine Archbold
Date:07/17/2018
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one at the RE-ROOFS:
following two reasons: All roofs shall be inspected prior to any roofing material being installed,If a.of is
r. I,as owner oi'thc property,or my employees with wages as their sole instulled without first obtaining sur inspection,I agree to remove ell new materials for
compensation,will do the work,and the structure is not intended or offered for inspection.
sal,(Sce.7044,Business&Professions Code)
z. f,as owner of the property,am exclusively contracting with licensed Signature ofApplicanc
contractors to construct the project(Sec.7044,Business&Professions Code). Date:07/17/2018
I hereby affirm under penalty of perjury one 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 Worker
Compensation,as provided for by Section 3700 of the Labor Code,for the
performance of the work£awhich 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 of the labor Code,for the performance of the work for which this California HeaRh&Safety Code,Sections 25505,25533,and 25534.t will
permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
a. 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 subject material,Additionally,should I use equipment at devices which emit hazardous
p yany person in any manner so as to become J to the air contaminants as defined by the Bay Area Air Quality Management District I
Worker's Compensation laws of California.If,after making this ca9ificate of will maintain compliance with the upertino MTal Cod, Chnptat 9.12 and
exemption,I became subject to the Worker's Compensation provisions of the the Health&Safety Co e, ons 255533,and 25534.
Labor Code,1 must forthwith comply with such provisions or this permit shall
be deemed revoked. Owner or authorized agent:
APPLICANT CERTIFICATION Date:07/1712018
I certify that I have read this application and state that the above Information is CONSTRUCT ON �,1 CY
correct.I agree to comply with all city and county ordinances and state laws I hereby affirm that there is a con it ion 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 07/17/2018
Professional