B-2018-1706 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMI : -
20891 MCCLELLAN RD CUPERTINO, CA 95014-2957 359 13 083 T NO. B 2018-1706
( ) GLEN GILBERT
SAN JOSE, CA 95154
OWNER'S NAME: DATE ISSUED: 11/01/2018
OWNER'S PHONE:
PHONE NO: (408) 377-9990
LICENSED CONTRACTOR'S DECLARATION
BUILDING PERMIT INFO:
License Class C-42 Lic. #677475
Contractor GLEN GILBERT Date 09/30/2019 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 of perjury one of the following two declarations: (N) SEWER LINE AND CLEAN-OUT ( BUILDING)
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.
.. have and will maintain Worker's Compensation Insurance asr
p ovided for by
Section 3700 of the Labor Code, for the performance of the work for which this
permit is issued.
APPLICANT CERTIFICATION Sq. Ft Floor Area: Valuation: $5000.00
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 359 13 083
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 EX
may accrue against said City in consequence of the granting of this permit. FIRES IF WORK IS NOT STARTED
Additionally, the applicant understands and will comply with all non-point WITE-IIN 180 DAYS OF PERMIT ISSUANCE OR
source regulations per the Cupertino Municipal Code, Section 9. 18. 180 DAYS FROM L
�-- AST CALLED INSPECTION.
Signature Date 11-01-2018 Issued by: Kim Dunbar
Date: 11/01/2018
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of the RE-ROOFS:
following two reasons: All roofs shall be inspected prior to any roofing material being installed. If a roof is
1. I, as owner of the property, or my employees with wages as their sole installed without first obtaining an inspection, I agree to remove all Zi
compensation, will do the work, and the structure is not intended or offered for inspection. new materials for
sale (Sec.7044, Business & Professions Code)
2. I, as owner of the property, am exclusively contracting with licensed Signature of Applicant:
contractors to construct the project (Sec.7044, Business & Professions Code). Date: 11-01-2018
I hereby affirm under penalty of perjury one of the following three declarations:
1. I have and will maintain a Certificate of Consent to self-insure for Worker's ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
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
2. I have and will maintain Worker's Compensation Insurance, as provided for by I have read the hazardous materials requirements
Section 3700 of the Labor Code, for the performance of the work for which this q nts under Chapter 6.95 of the
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
3. I certify that in the performance of the work for which this permit is issued, I Health & Safety Code, Section 25532(a) 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 hazardous
Worker's Compensation laws of California.. If, after making this certificate of air contaminants as defined by the Bay Area Air Quality Management District I
exemption, I become subject to the Worker's Compensation provisions of the will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and
Labor Code, I must forthwith comply with such provisions or this permit shall the Health & Safety Code, Sections 25505, 25533, and 25534.
be deemed revoked, }
Owner or authorized agent:
APPLICANT CERTIFICATION Date: 11-01-2018
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 theerformance
relating to building construction, and hereby authorize representatives of this city of work's for which this permit is issued (Sec. 3097, Civ C. p
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 DEC A kTIO T
Code, Section 9.18. 1 understand my plans shall be used asublic records.
P s
Signature Date 11-01-2018 Licensed
Professional