B-2019-0135 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS;
CONTRACTOR:
18811 LOREE A'VE CUPERTINO,CA 95014-3616(375 13 021) JOSE SANTOS GOMEZ PERMIT'NO:B-2019-0135
PLUM13ING INC
LOS BANOS,CA 93635
OWNER'S NAME: DATE ISSUED:01/22/2019
OWNER'S PHONE:
PHONE NO:(408)849-7292
LICENSED CONTRACTOR'S DECLARATION
BUILDING PERMIT INFO: ..
License Class C36 Dc.#1007487
Contractor JOSE SANTOS GOMEZ PLUMBING INC Date 09/30/2019 X BLDG _ELECT X PLUMB
_MECH X
I hereby affirm that I am licensed under the provisions of Chapter 9(commencing 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:
TRENCH-LESS 4"SEWER LINE REPLACEMENT
I hereby affirm under penalty of perjury one of the following two declarations: CLEAN-OUT TO 2 WAY CLEAN-OUT FROM PROPERTY
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,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:$7800.00
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above -
information is correct.I agree to coin*with all city and county ordinances APN Number: ' Occupancy Type:
and state laws relating to building construction,and hereby authorize 375 13 021
representatives of this city to enter upon the above Menficnet1 property for -
inspection purposes. (We)agree to save indemnify ani keep hardlle-Whe... - - - - -- -------- -- --- -- -- - — `"----- — ---
City of Cupertino.ngajn§t liabilities,judgments,costs,and expenses Which PERMIT EXPIRES IF WORK IS NOT STARTED accrue against said City in 00WCitience of the-granting.of this
Ad ,ditionally-the appilMfrinprstands rim comply with ail permit.non-poiwimIN 180 DAYS OF PERMIT ISSUANCE OR
nt
... .
source regu,ati6ns per the,G- p in ma al Cpde,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
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Bignatr (.--- ,--....... Date 01/22/2019 Issued by:Jasmine Archbold
(..../ ...._
Date:01/22/2019
OWNER-BUILDER DECLARATION
RE-ROOFS:
I hereby affirm that I am exempt from the Contractor's License Law for one of the
following two reasons: All roofs shall be inspected prior to any roofing material being installed.If a roof is
installed withrad first obtaining an inspection,I agree to remove all new materials for
t I,as owner of the property,or my employees with wages as their sole
•
compensation,will do the work,and the structure is not intended or offered for inspection.
sale(Sec.7044,Business&Professions(ode)
2. 1,as owner of the property,an.exclusively contracting with licensed Signature of Applicant:
contractors to construct the project(Sec.7044,Business&Professions Code). Date:01/22/2019
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
California Health&Safety Code,Sections 25505,25533,and 25534. I will
Section 3700 of the Labor Code,for the performance of the work for which this
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 isued. Health&Safety Code,Section 25532(a)should I store or handle hazardous
material.I
material. Additionally,should I use equipment or devices which emit h. a4d. s
shall not employ any person in any manner so as to become subject to the
i ...—
air contaminants as defined by MrAlaAfr-Quality Managem- District I
Worker's Compensation laws of California. If,after making this certificate of will maintain compliance with the Cupertino Municipal-Code,Ch t•ter 9.12 and
exemption.I become subject to the Worker's Compensation provisions of the , the Health&Safety e,Sections 25505,255- ,a 34.
Labor Code,I must forthwith comply with such provisions or this permit shall „.,-"-- —......--
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be deemed revoked. Owner or authorized ag• 1 ,-
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 Lenders 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
my plans shall be used as public records.
Code,Section 9.18. I understand ARCHITECT'S DECLARATION
Licensed
Signature Date 01/22/2019 Professional