B-2018-1392 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2018-1392
19505 GREENWOOD CT CUPERTINO,CA 95014-3346(369 14 024) OVERMILLER INC
CONCORD,CA 94520
OWNER'S NAME: DATE ISSUED:08/17/2018
OWNER'S PHONE: PHONE NO:(
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class B.Lie.#323839
X BLDG—ELECT X PLUMB
Contractor OVERMILLER INC Date 07/31/2020 —
I hereby affirm that I am licensed under the provisions of Chapter 9(commencing —MECII—RESIDENTIAL Ys COMMERCIAL
with Section 7000)of Division 3 of the Business&Professions Code and that my
license is ht full force and effect. JOB DESCRIPTION:
INSTALL PROPERTY LINE CLEANOUT,
I hereby affirm ander penalty of pm•jury one of the following twodeclarations;
r, I have and will maintain a.artifiente of consent to self-fissure for Worker's
Compensation,as provided for by Section 3700 opine Labor Code,for die
(�//
is issued, Sq.Ft Floor Area: V.Imuimn$3500.00
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 14024
representatives of this city to enter upon the above mentioned properly 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 cense uance of the granting of this permit. WITHIN 180 DAYS OF PERMIT ISSUANCE OR
Additionally,the applicant under at� nd will comply with all non-point
source regu
Date 8.17.18 Issued by:Jasmine Archbold.
Date:08/17/2018
OWNER-BUILDLR DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law I'or one of the RE-ROOFS:
following two reasons: All root's shall be inspected prior to any rooting material being installed.If a roof is
E. 1,as owner of the property,or my employees with wages as their sole installed without first obtaining an inspection,1 agree to remove all new materials For
compensation,will do the work,and the structure 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 Signatim ofApplia.nu
contractors to construct the project(Sec.7044,Business&Professions Code), Date:8.17.18
1 hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTERi. 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,far the
performance of the 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 of the Labor Code,for the performence of the work for which this California Health&Safety Cade,Sections 25505,25533,and 25534.I will
mit is issued. maintain compliance with tee Cupertino Municipal Code,Chapter 9,12 and the
pa Health&Safety Code,Section 25532(.)should I store or handle hazardous
s. 1 all noify that in they person in of the work for which this permit is issued,l anterial.Additionally,should 1 use equipment or devices which emit hazardous
shall not employ any person in any manner so as to become subject to the air contaminants as([alined by the Bay Area Air Quality Mr�1ua 'went District l
Worker's Compensation laws of California,If,alter making this certificate of will maintain compliance with the Cupertino Municipal Coda;Gha r 9.12 anA
exemption,I become subject m the Worker's Compensation provisions of the the Health&
Labor Code,I must forthwith comply with such provisions or this permit shall
be deemed revoked. Owner or authorized ag t: --
APPLICANT CERTIFICATION Date:8.17 18
I certify that I have read this application and state that the above information is CONSTRUCTION LEN IN G AGENCY
correct.I agree to comply 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.)
toenter 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 nen-point source regulations per the Cupertino Municipal ARCHI'1'14C'1"S DECLARATION
Code,Section 9,18. 1 understand my plans shall be used as public records.
Licensed
Signature Date 8.17.18
Professional