B-2019-0078 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO: B-2019-0078
10169 N BLANEY AVE CUPERTINO, CA 95014 (316 23 040) M G CONSTRUCTORS
& ENGINEERS INC
MORGAN HILL, CA
95037
OWNER'S NAME: DATE ISSUED: 01/11/2019
OWNER'S PHONE: PHONE NO: (408) 842-5599
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class A B Lic. #642058
Contractor M G CONSTRUCTORS & ENGINEERS INC Date 07/31/2019 X BLDG — ELECT _ PLUMB
I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing _
MECH X RESIDENTTAL , COMMERCIAL
with Section 7000) of Division 3 of the Business & Professions Code and that my
license is in full force and effect. JOB DESCRIPTION:
FOUNDATION REPAIR
I hereby affirm under penalty of perjury one of the following two declarations:
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 workk for which this permit is issued.
2. 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: $5300.00
APPLICANT CERTIFICATION
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 authorize316 23 040
representatives of this city to enter upon the above mentioned p.re,perty for ~ r
inspection purposes. (W ) agree to save indemnify a_rLdAk 'ep harmless the
City of Cupertino agains abilities, judgments,�s�ts, and expenses which PERMIT EXPIRES IF WORK IS NOT STARTED
may accrue against sa' ity in consequence a�-,t�he granting of this permit.
Additional) the li t understands and will coni, I with all non-point
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
Y, p p Y p
source regulations Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
Signature eel Date 1-11-2019 Issued by: Kim Dunbar
Date: 01/11/2019
OWNER-BU ER DE,CLARATIO
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 new materials for
compensation, will do the work, and the structure is not intended or offered for inspection.
sale (Sec.7044, Business & Professions Code)
2. 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: 1-11-2019
I hereby affirm under penalty of perjury*one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
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. ' HAZARDOUS MATERIALS DISCLOSURE
2. 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 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
material. Additionally; should I use equipmenk or devices which emit hazardous
shall not employ any person in any manner so as to become subject to the air contaminants as defined by the Bay Area Air Qualit �aiiwg ment DistKjrt T�
Worker's Compensation laws of California. If, after making this certificate of will maintain compliance with the Cupertino Muni al Code, pxe° .12 and
exemption, I become subject to the Workers Compensation provisions of the the Health & Safety Code, Section25533 a 5534.
Labor Code, I must forthwith comply with such provisions or this permit shall r
be deemed revoked. Owner or authorized agent:
APPLICANT CERTIFICATION Date: 1-11-2019 4°
I certify that I have read this application and state that the above information is CONSTRUCTI /END N1
correct. I agree to comply with all city and county ordinances and state laws I hereby affirm that there is a construction lepding agency for erformance
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.
Signature Date 1-11-2019 Licensed
Professional